Insurance Continuing Education - Contracts

Insurance Continuing Education - Contracts

In the absence of fraud, all statements made by applicants or Insureds will be deemed to be representationsand not warranties.  No statement made for the purpose of affecting coverage will avoid coverage or reduce benefits unless contained in a written application signed by the Contract Holder and a copy of such documents has been furnished to the Contract Holder.

Eligibility for coverage under this Contract is determined by medical risk classifications applicable to the applicant and his or her dependents.  Among the factors we consider when making our underwriting decision are the medical information requested on the application, and the sex and age of the applicant and his or her dependents.

Material Misrepresentations, omissions, concealment of facts and incorrect statements made on an application or a medical statement by an applicant, Insured or a Contract Holder which is discovered within two years of the issue dateof the Contract may prevent payment of benefits under this Contract and may void this Contract for the individual making the misrepresentation, omission, concealment of facts or incorrect statement.  Fraudulent misstatementsin the application or medical statement discovered at any time,may result in voidance of this Contract or denial of any claims for the individual making or responsible for the fraudulent misstatement.

In the event of fraud or misrepresentation pertaining to, but not limited to, medical information, geographical area, or the sex and/or the age of applicant or his or her dependents made on an application or medical statement by an applicant, Contract Holder or Insured, the sole liabilityof YOUR INSURANCE COMPANY shall be the return of any unearned Premium, less benefit payments.  However, at our discretion, we may elect to cancel the Contract with forty-five (45) days prior written notice (Time may vary by state regulation &/or company practice) or continue this Contract provided that the Contract Holder makes payment to us for the full amount of the Premium which would have been in effect had the true facts been stated by the applicant, Contract Holder, or Insured.



Bernadette was diagnosed with breast cancer in Oregon.  Her doctor in Oregon told her that she needed surgery as soon as possible.  However, since she was not employed and had no insurance, she decided to move back home to Indiana.

She found a job in Indianapolis, but it had no benefits.  Therefore she applied for an individual major medical policy.  She did not tell the agent about her cancer and the policy was issued on a standard basis with no riders.

60 days after the policy was issued she had a  "routine" mammogram" which "discovered"


(Continued from previous page) the cancer.  She told the radiologist at the clinic that she had had a mammogram about a year earlier, at a public health clinic.  She did not mention the finding, however.  She was immediately admitted to a hospital in Indianapolis and a mastectomy was performed.

During a routine claims review, the insurer sent an inquiry to the Public Health Service in Oregon, which duly reported the earlier findings.  Based upon these findings, the insurer canceled the policy based upon a material misrepresentation and refused to pay for any of the medical costs.

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