NY-Life-Accident-and-Health Exam Dumps - Insurance Licensing Life, Accident, and Health Questions and Answers

Accident and health (A & H) policies pay benefits only for losses caused by covered injuries or sickness, and they also list specific exclusions —situations for which the insurer will not pay. A very common exclusion across A & H contracts is intentionally self-inflicted injury . The reasoning is that insurance is intended to protect against fortuitous (accidental, unintended) loss, not losses deliberately caused by the insured. Therefore, injuries resulting from intentional self-harm are typically excluded from coverage, and claims arising from such acts are not payable under standard policy language.

The other options do not represent common exclusions. Emergency room coverage is generally a covered service under major medical plans (though subject to copays, deductibles, medical-necessity rules, and network provisions). Coordination of benefits is not an exclusion—it is a claims provision used when an insured has more than one health plan to determine which plan is primary and how benefits are coordinated. Chiropractic services may be covered or limited depending on plan design, but they are not universally excluded in the same way as intentional self-inflicted injury.

The correct answer is A. concealment . In insurance, concealment means an applicant or insured intentionally fails to disclose a material fact that should be made known to the insurer. A material fact is any information that would affect the insurer’s decision to issue the policy, set the premium, or determine the scope of coverage. Because insurers rely on full and truthful disclosure during underwriting, concealment can be treated as a form of misrepresentation and may give the insurer grounds to deny a claim or rescind the policy, depending on the circumstances and applicable law.

The other choices do not match this definition. Estoppel is a legal principle that can prevent a party from asserting a right when its own actions have caused another to rely to their detriment. Remission is not the standard insurance term for withholding information in underwriting. Twisting is an unfair trade practice involving inducing a policyowner to replace existing insurance using misleading comparisons. Since the question asks specifically about intentionally withholding information from an insurer, the correct term is concealment .

The correct answer is D. routine adult dental services. The Affordable Care Act (ACA) prohibits health insurers from placing lifetime or annual dollar limits on coverage for Essential Health Benefits (EHBs) . These essential health benefits include services such as laboratory services, mental health and substance use disorder services, and maternity and newborn care . Because these categories are designated as essential health benefits, insurers are not allowed to impose annual or lifetime dollar caps on them under ACA-compliant health plans.

However, routine adult dental services are not included in the ACA’s list of essential health benefits . While pediatric dental services are included as an essential health benefit category, routine dental coverage for adults is generally offered as an optional or separate benefit. Because it is not classified as an essential health benefit under the ACA, insurers may legally apply dollar limits or other coverage limitations to routine adult dental services depending on the policy design.

Therefore, under ACA regulations applicable to health insurance policies and marketplace plans beginning in 2014, dollar limits are prohibited for essential health benefits but may still apply to non-essential benefits , such as routine adult dental care .

The correct answer is reaches age 26 . Under the Affordable Care Act (ACA) , health insurance plans that offer dependent coverage must allow children to remain on their parent’s health insurance policy until age 26 . This rule applies regardless of several factors that previously affected eligibility under older insurance plans. For example, the dependent child does not need to live with the parent, be financially dependent, be a student, or be unmarried to remain eligible for coverage under the parent’s policy.

This provision was introduced to expand access to health coverage for young adults, who historically had higher uninsured rates when transitioning from school to the workforce. As a result, individuals can remain on their parents’ employer-sponsored or individual health plans until their 26th birthday , even if they are married or no longer living at home.

The other options are incorrect because the ACA does not terminate dependent coverage based on marriage , graduation from college , or age 19 . The uniform federal rule established by the ACA is that dependent coverage must be available until age 26 , making Choice C the correct answer.

The correct answer is annual open enrollment . In accident and health insurance, open enrollment is the designated period during which eligible employees may enroll in a health plan, remain in their current plan, or switch to another available plan option , such as changing from one HMO or managed care arrangement to another health plan offered by the employer. This enrollment window is generally provided once each year, which is why it is called annual open enrollment.

This period is important because outside of open enrollment, employees are usually allowed to make changes only if they experience a qualifying life event , such as marriage, divorce, birth of a child, or loss of other coverage. During annual open enrollment, employees review benefits, costs, provider networks, and coverage features before selecting the plan that best fits their needs for the upcoming coverage period.

The other options are incorrect because “annual gatekeeper enrollment” and “coverage authorization period” are not standard insurance terms for selecting or changing plans, and “employer sponsored health plan” refers to the type of coverage arrangement itself, not the election period. Therefore, annual open enrollment is the correct term.

A fixed annuity provides payments (or credited interest during accumulation) based on a guaranteed rate and/or guaranteed payout set by the insurer. Because the payment amount is generally level once annuitized (unless an inflation rider or increasing-payment option is selected), the key drawback is inflation risk : over time, rising prices can reduce the purchasing power of those fixed payments. In other words, the annuitant may receive the same dollar amount each period, but that amount may buy less in the future.

Option B describes a feature more consistent with variable annuities , where benefits are not guaranteed at a specific level because values depend on investment performance. Option C is also a characteristic of variable annuities (separate account investments and fluctuating returns), not fixed annuities. Option D is not a standard limitation of fixed annuities; payout periods depend on the selected settlement option (life, period certain, joint life, etc.), not an automatic “2 years after death” cap. Therefore, the commonly tested disadvantage of a fixed annuity is the potential erosion of buying power due to inflation.

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In insurance terminology, the cause of a loss is known as a peril . A peril is the specific event or cause that results in damage, injury, or financial loss. Common examples of perils include fire, theft, accident, illness, disability, or death . In life and health insurance, the insured event—such as death in life insurance or sickness and accidental injury in health insurance—is considered the peril that triggers the insurer’s obligation to pay benefits under the policy. Insurance policies are designed to provide financial protection against losses that result from covered perils.

It is important to distinguish a peril from other related insurance concepts. A hazard is a condition or situation that increases the likelihood or severity of a loss caused by a peril. Hazards are typically categorized as physical hazards (such as icy roads or faulty wiring), moral hazards (dishonesty or fraudulent behavior), and morale hazards (carelessness because of insurance coverage). An exposure refers to the possibility of loss, while risk refers to the uncertainty regarding the occurrence of a loss. Therefore, the term that specifically describes the direct cause of a loss is a peril .

Workers’ Compensation is a form of insurance that provides benefits to employees who suffer work-related injuries or occupational illnesses . It is designed as a no-fault system , meaning employees receive benefits regardless of who caused the accident, while employers are generally protected from lawsuits related to workplace injuries. Workers’ Compensation typically provides several types of benefits, including payment of necessary medical expenses , replacement of a portion of lost wages , and coverage for occupational illnesses or diseases that arise from employment conditions. In cases of severe injury or death, additional disability or survivor benefits may also be provided.

However, Workers’ Compensation does not provide benefits for pain and suffering . Compensation for emotional distress or general suffering is usually associated with civil liability lawsuits, not with Workers’ Compensation benefits. The system focuses primarily on economic losses —such as medical costs and lost income—rather than non-economic damages. Because of this trade-off, employees receive quicker access to benefits without needing to prove employer negligence, but they also give up the right to sue the employer for additional damages like pain and suffering.

The correct answer is Employer . In a key person insurance policy , the business purchases life insurance on the life of an employee, owner, or executive whose services are considered especially valuable to the company. In this arrangement, the business is the policyowner , pays the premiums, and is also named as the beneficiary . If the key person dies, the death benefit is paid to the employer to help offset the financial loss that may result from the death of that important individual.

The purpose of key person insurance is to protect the business against losses such as reduced revenues, replacement and training costs, disruption of operations, loss of credit, or the expense of finding a suitable successor . The policy is not intended primarily to provide personal family protection for the insured employee; that would normally be handled by an individually owned life insurance policy.

The other choices are incorrect because the employee, the insured’s spouse, or a business partner would not ordinarily be the beneficiary unless the policy were structured differently from a standard key person arrangement. In the typical and tested form of key person insurance, the employer is the beneficiary.