Maine · Life, Accident & Health Sample Interactive Mind Map
Required A&H Policy Provisions
A visual breakdown of Required A&H Policy Provisions — one of the concepts you can count on seeing on the exam.
The TESTivity Interactive Mind Mapping Graphic we picked for the Maine Life & Health sample is Required A&H Policy Provisions — and this is a concept you can count on seeing on your pre-licensing exam. Get the structure straight once and those questions turn into free points.
So explore it. Click through, see how the pieces relate, and let the layout do some of the remembering for you.
Explore by topic
Choose a Cluster to Study
Every individual A&H policy is built on the same legal skeleton.
State law — modeled on the NAIC Uniform Policy Provisions Law — requires certain provisions in every individual accident & health policy. They protect the policyholder, and the insurer cannot contract them away. Start with the two that define what the contract is and how long the insurer can attack it.
State law — modeled on the NAIC Uniform Policy Provisions Law — requires certain provisions in every individual accident & health policy. They protect the policyholder, and the insurer cannot contract them away. Start with the two that define what the contract is and how long the insurer can attack it.
🧠 Anchor Idea — “Required = the insured wins ties”
If a policy leaves out a required provision — or writes one that is less favorable than the law — the policy is read as if the required version were in it. These are a floor the insurer can rise above but never sink below.
📄
Entire Contract; Changes
The policy plus any attached application = the entire agreement. Nothing outside that document counts. No agent can change the policy — a change is valid only when it is endorsed in writing and signed by an executive officer of the insurer.
Why it protects youThe insured can trust the written document. A producer’s side-of-the-mouth promise (“don’t worry, that’s covered”) is unenforceable unless it’s actually in the policy.
⏳
Time Limit on Certain Defenses
The A&H version of incontestability. After the policy has been in force a stated period — typically 2 years (some states 3) — the insurer cannot use application misstatements to deny a claim. The one carve-out: fraudulent misstatements, which stay contestable forever.
How they test thisPre-existing condition limits run on their own clock (often 1–2 years), separate from the contestable period. The stem usually plants an innocent omission after the window closes — the answer is the insurer is stuck.
The trap they setThey’ll dress up an innocent omission as if it were fraud, hoping you let the insurer rescind years later. Read for the word that signals intent to deceive. No deliberate lie = no fraud exception = once the contestable period closes, the insurer cannot rescind for that misstatement.
Premiums lapse. The law builds in a runway and a second chance.
The grace period keeps a late-paying policy alive for a window; reinstatement brings a lapsed one back. The exam loves the exact numbers attached to each.
The grace period keeps a late-paying policy alive for a window; reinstatement brings a lapsed one back. The exam loves the exact numbers attached to each.
📅 Monthly mode
📆 All other modes
Grace period
7 days after the due date.Grace period
31 days for quarterly, semi-annual, and annual.Coverage
Policy stays fully in force; a claim during grace is covered.If still unpaid
Policy lapses at the end of grace — but a loss that occurred before then is still paid.💡
Don’t confuse it with life insurance
In life insurance the grace period is a flat 30 or 31 days regardless of how you pay. In A&H it depends on the mode: monthly = 7, everything else = 31. That split is the trap.
🔄
Reinstatement
Bringing a lapsed policy back to life
- Automatic: if the insurer (or its agent) accepts a late premium without asking for a reinstatement application, the policy is reinstated on the spot.
- Application route: if a reinstatement application is required, the insurer has 45 days to approve or deny. Silence past 45 days = automatic reinstatement.
- Coverage resumes on two clocks: accidental injury is covered immediately; sickness is covered only after a waiting period (usually 10 days).
The logic behind the 10 days
Accidents are sudden and can’t be faked into existence; a sickness might already be brewing when someone “happens” to reinstate. The waiting period stops an insured from reinstating because they feel ill, filing, then lapsing again.
The people who write these questions love to……swap the two clocks. Lock it: accident = immediate, sickness = ~10-day wait. And remember the insurer’s deadline is 45 days to act on a reinstatement application.
A claim moves down a fixed timeline — and the exam wants the three numbers in order.
The insured speaks first (notice), the insurer responds (forms), the insured documents the loss (proof). Memorize the sequence and the deadlines fall into place.
The insured speaks first (notice), the insurer responds (forms), the insured documents the loss (proof). Memorize the sequence and the deadlines fall into place.
🧠 Memory Aid — 20 → 15 → 90
20 days: insured gives Notice of claim · 15 days: insurer sends Forms · 90 days: insured files Proof of loss. Think “Notice, Forms, Proof.”
📧
Notice of Claim — within 20 days
The insured gives written notice of a covered loss within 20 days (or as soon as reasonably possible), so the insurer can investigate promptly.
📝
Claim Forms — insurer furnishes within 15 days
After getting notice, the insurer must supply claim forms within 15 days. Miss that, and the insured may submit proof in any written form describing the loss.
📋
Proof of Loss — within 90 days
The insured files written proof within 90 days of the loss (for continuous disability, within 90 days of the end of each period the insurer is liable for). Late filing isn’t auto-denied if the delay wasn’t intentional or fraudulent.
⏳ Time of Payment
Disability income benefits are paid at least monthly.
Hospital / medical expense benefits are paid immediately on receipt of due proof.
💵 Payment of Claims
Disability income is paid to the insured.
Medical expense goes to the insured — unless benefits were assigned to the provider.
🩺
Physical Examination & Autopsy
The insurer’s right to verify — on its own dime
- While a claim is pending, the insurer may require physical exams as often as reasonably necessary — not unlimited, and always at the insurer’s expense.
- For a death claim, the insurer may require an autopsy where not prohibited by law.
- Purpose: confirm a disability is continuing and that the claimant truly meets the policy’s definition of a covered loss.
Two provisions bookend the relationship: when you can sue, and when you can walk away.
Legal Actions sets the window for suing the insurer. Free Look lets a brand-new policyholder change their mind. Both are pure-number questions on the exam.
Legal Actions sets the window for suing the insurer. Free Look lets a brand-new policyholder change their mind. Both are pure-number questions on the exam.
⚖️ Earliest you can sue
⏱️ Latest you can sue
Minimum wait
No lawsuit until at least 60 days after submitting proof of loss — this gives the insurer time to process and respond.Statute of limitations
Must sue within 3 years of when proof of loss was due (some states differ). After that, the right to sue is gone.How they test thisThe 60-day minimum is the most frequently tested number here. A stem will say “submitted proof 40-something days ago, wants to sue now” — the answer is not yet, wait until 60 days.
👀
Right to Examine (Free Look)
A new policyholder’s no-questions-asked exit
- A new individual health policy can be returned within a stated window — typically 10 days from delivery (some states / policy types require longer).
- No reason required: the insured can return it for any reason, or none.
- Full refund: every premium paid comes back — the insurer keeps nothing.
🎯
Top Exam Tips — Required A&H Provisions
1. Required = a floor. If a provision is missing or weaker than the law, the policy reads as if the required version applied.
2. Entire contract: policy + application is the whole deal; only a written officer endorsement changes it — never an agent’s word.
3. Time limit on defenses: ~2 years, then no more rescinding on application errors — except fraud. Pre-existing limits run on a separate clock.
4. Grace period: monthly = 7 days, all other modes = 31 days. (Life is a flat 30/31 — don’t mix them up.)
5. Reinstatement: insurer has 45 days to act; accident covered immediately, sickness after ~10 days.
6. Claims timeline 20 → 15 → 90: Notice (insured, 20) → Forms (insurer, 15) → Proof (insured, 90).
7. Legal actions: wait at least 60 days after proof to sue; sue within 3 years. Free look: ~10 days, full refund.
2. Entire contract: policy + application is the whole deal; only a written officer endorsement changes it — never an agent’s word.
3. Time limit on defenses: ~2 years, then no more rescinding on application errors — except fraud. Pre-existing limits run on a separate clock.
4. Grace period: monthly = 7 days, all other modes = 31 days. (Life is a flat 30/31 — don’t mix them up.)
5. Reinstatement: insurer has 45 days to act; accident covered immediately, sickness after ~10 days.
6. Claims timeline 20 → 15 → 90: Notice (insured, 20) → Forms (insurer, 15) → Proof (insured, 90).
7. Legal actions: wait at least 60 days after proof to sue; sue within 3 years. Free look: ~10 days, full refund.
Exam vocabulary
Key Terms to Know
Required Provision
A provision mandated by state law that must appear in every individual A&H policy; consumer protections the insurer cannot contract away.
Entire Contract
Policy + attached application = the complete agreement; changes are valid only by written endorsement signed by an executive officer.
Time Limit on Defenses
After roughly 2–3 years, the insurer cannot use application misstatements to deny a claim — except fraudulent misstatements.
Grace Period (A&H)
Monthly mode = 7 days; all other modes = 31 days. Coverage stays in force; claims during grace are paid.
Reinstatement
Restoring a lapsed health policy; insurer has 45 days to act; accident coverage resumes immediately, sickness after ~10 days.
Notice of Claim
The insured must notify the insurer of a covered loss within 20 days (or as soon as reasonably possible).
Claim Forms
The insurer must furnish claim forms within 15 days of receiving notice; otherwise the insured may use any written proof.
Proof of Loss
Written documentation of the loss the insured must file within 90 days of the covered loss.
Physical Exam / Autopsy
The insurer’s right to examine the insured at the insurer’s expense while a claim is pending; autopsy where not prohibited by law.
Legal Actions
No suit until at least 60 days after proof of loss; must sue within 3 years of when proof of loss was due.
Free Look (A&H)
Typically a 10-day right to return a new health policy for a full premium refund, for any reason.
Uniform Policy Provisions Law
NAIC model law establishing the standardized required (and optional) provisions for individual A&H policies.
Like learning this way? There's a whole library of them.
If the old manual you inherited from the office breakroom isn't cutting it and this format fits how your brain actually works, you'll want the rest. There are 52 Interactive Mind Maps like this one in the TESTivity Platinum Life, Accident & Health package — covering the full curriculum, right alongside the practice questions, exam simulators, and study guides.
🧭
Studying for a different state?
This concept is the same wherever you sit for the exam — but your study guide and prep package should match your state. Find your state's L&H and P&C guides here →