Insurance Licensing Ok-Life-Accident-and-Health-or-Sickness-Producer - Oklahoma Life, Accident, and Health or Sickness Producer Exam

The Oklahoma Unfair Claims Settlement Practices Act, under Title 36 O.S. § 1250.5, defines practices that constitute unfair or deceptive acts in the settlement of insurance claims. Knowingly misrepresenting pertinent facts or policy provisions related to coverage to a claimant is explicitly listed as an unfair practice, as it misleads policyholders and undermines fair claim handling.

Option A: Correct. Misrepresenting facts or policy provisions is an unfair claims settlement practice under Oklahoma law.

Option B: Incorrect. There is no specific 45-day requirement to interview parties in the Act; timelines relate to acknowledging or settling claims.

Option C: Incorrect. Maintaining an audit trail is a best practice but not explicitly an unfair claims settlement practice.

Option D: Incorrect. Incomplete policy notes are not specifically cited as an unfair practice under the Act.

This question aligns with the Prometric content outline under “State Insurance Statutes, Rules, and Regulations,” which covers unfair claims practices.

Underwriting is the process by which an insurer evaluates an applicant’s risk profile to determine whether to issue a policy, what coverage to offer, and at what premium rate. This involves assessing factors such as medical history, lifestyle, and financial information to ensure the applicant meets the insurer’s standards.

Option A: Incorrect. Classification refers to grouping applicants into risk categories (e.g., standard, substandard) during underwriting, not the entire process.

Option B: Incorrect. Risk pooling is the practice of spreading risk across a group of policyholders, not the decision to issue a policy.

Option C: Correct. Underwriting is the process of evaluating and deciding whether to issue a policy.

Option D: Incorrect. Selection is a component of underwriting but not the term for the entire process.

This question aligns with the Prometric content outline under “Underwriting,” which covers the principles and processes of risk assessment.

Thegrace periodin life and health insurance policies, as mandated by Oklahoma law (Title 36 O.S. § 4005 for life, § 4405 for health), is a period (typically 31 days) after a premium due date during which the policy remains in force, protecting the policyowner from an unintentional lapse. If the insured dies during the grace period, the death benefit is payable, minus any overdue premiums.

Option A: Incorrect. The period after premium payment but before policy issuance is the underwriting or application phase, not the grace period.

Option B: Incorrect. This is similar to Option A and does not describe the grace period.

Option C: Incorrect. The time between death and benefit payment is the claim processing period, not the grace period.

Option D: Correct. The grace period protects against unintentional policy lapse due to late premium payment.

This question falls under the Prometric content outline section on “Provisions, Options, Exclusions, Riders, Clauses, and Rights,” which covers grace period provisions.

Theentire contract provision, mandated in Oklahoma for life and health insurance (Title 36 O.S. § 4001 for life, § 4405 for health), specifies that theentire contractconsists of the policy, any attached endorsements or riders, and a copy of theapplicationif endorsed upon or attached to the policy at issuance. This ensures no external documents can alter the agreement unless included. Clauses and provisions are part of the policy itself, while credit reports are used in underwriting but not part of the contract.

Option A: Incorrect. Clauses are components of the policy, not a separate item added to the entire contract.

Option B: Incorrect. Credit reports are underwriting tools, not part of the contract.

Option C: Incorrect. Provisions are part of the policy, not a distinct addition.

Option D: Correct. The application, when attached, is part of the entire contract.

In group health insurance, the employer or group sponsor receives themaster policy, while employees covered under the plan are issued acertificate of insurance, which summarizes their coverage but is not the policy itself, as per Oklahoma’s regulations (Title 36 O.S. § 6060.3).

Option A: Incorrect. Employees do not receive individual policies; the employer holds the master policy.

Option B: Incorrect. The contract is the master policy, not issued to employees.

Option C: Incorrect. “Covenant” is not an insurance term.

Option D: Correct. Employees receive a certificate of insurance.

Aninducementin insurance involves offering something of value to persuade someone to purchase a policy, which is consideredrebatingand prohibited in Oklahoma unless allowed under specific exceptions (Title 36 O.S. § 1204). Oklahoma allows gifts valued at $100 or less as non-rebating promotional items, so a gift under $100 is not an inducement. Other actions, like promising employment, offering premium payment favors, or giving high-value merchandise, are considered inducements.

Option A: Incorrect (is an inducement). Promising employment to secure a policy sale is rebating.

Option B: Correct (is not an inducement). A gift valued less than $100 is permitted and not considered rebating.

Option C: Incorrect (is an inducement). Special favors in premium payments are rebating.

Option D: Incorrect (is an inducement). Giving merchandise worth $250 exceeds the $100 limit and is rebating.

Theunpaid premium Uniform Optional Provisionin health insurance policies, as recognized in Oklahoma (Title 36 O.S. § 4405), allows the insurer to deduct any unpaid premiums from a claim payment if a claim becomes payable while premiums are overdue. This ensures the policy remains in force and the claim is paid, net of the owed premium.

Option A: Incorrect. The claim is not denied; the premium is deducted from the payment.

Option B: Incorrect. The policy is not cancelled; the unpaid premium is addressed via the claim.

Option C: Correct. The unpaid premium is deducted from the claim payment.

Option D: Incorrect. The claim is not delayed; the premium is settled with the claim payment.

This question falls under the Prometric content outline section on “Provisions, Options, Exclusions, Riders, Clauses, and Rights,” which covers health insurance policy provisions.

Aninsuredis the person covered by an accident and health insurance policy and entitled to reimbursement for covered health care expenses, as defined in Oklahoma’s Insurance Code (Title 36 O.S. § 4401). The insured (or their assignee, e.g., a provider) receives benefits for services like medical treatments or hospital stays.

Option A: Incorrect. An insurer is the company issuing the policy, not receiving reimbursement.

Option B: Correct. The insured is entitled to reimbursement for covered health care expenses.

Option C: Incorrect. A practitioner provides services, not receives policy reimbursements.

Option D: Incorrect. A PPO is a network of providers, not an individual entitled to benefits.

Health Maintenance Organizations (HMOs) focus on preventive and essential medical care within a network.Adult routine eye examinationsare often excluded from HMO coverage, as they are considered non-essential or covered under separate vision plans. Other services like emergency care, physical exams, and surgeries are typically covered, as per Oklahoma’s managed care regulations (Title 36 O.S. § 652 et seq.).

Option A: Incorrect. Out-of-area emergency services are generally covered by HMOs.

Option B: Correct. Adult routine eye examinations are often excluded or require separate coverage.

Option C: Incorrect. Physical examinations are typically covered as preventive care.

Option D: Incorrect. In-patient surgeries are covered as essential medical services.

Most life insurance policies include asuicide clause, typically lasting 2 years in Oklahoma (Title 36 O.S. § 4004), which limits the insurer’s liability if the insured commits suicide within that period. If suicide occurs within the clause’s timeframe (e.g., 13 months), the insurer is generally not liable to pay the death benefit and instead refunds the premiums paid. However, the question emphasizes the policy’s expressed provision limiting liability, suggesting no payout beyond premiums, making “not liable to make any payouts” the most accurate choice. Insanity is not a standard exception unless specified.

Option A: Incorrect. While premium refunds are common, the question emphasizes no payouts, aligning with the provision’s limit.

Option B: Correct. The insurer is not liable to make any payouts due to the suicide clause.

Option C: Incorrect. The full value is not paid within the suicide clause period.

Option D: Incorrect. Insanity is not a standard exception in suicide clauses unless explicitly stated.