Free Utah Accident & Health practice questions

Answer: A. It is properly given, because the rule lets notice of loss go to the insurer or an authorized agent.

Utah Admin. Code r. 590-192-6(1)(b) provides that a notice of loss may be given to an insurer or to an authorized agent, so telling the agent is a permitted way to give notice. The rule attaches no condition that the insurer hear from the insured directly, that the agent forward the notice in writing within a set number of days, or that the policy name the agent as the notice address. Whether a notice is timely is a separate question, which the rule measures against the policy terms, the rule itself, and Section 31A-21-312.

Answer: D. The federal program meets Utah's training and examination requirements for that license.

Rule R590-244-8(2) requires a person acting as a navigator in Utah to complete the federal navigator training and certification program under PPACA, administered through the U.S. Department of Health and Human Services, and subsection (3) treats someone who has done so as having completed Utah's required training and examination for a navigator license. Subsection (3) leaves no additional Utah producer examination or Utah course to complete for the navigator license, and the rule gives the federal program that effect directly rather than limiting it to continuing education credit.

Answer: B. The procedure conflicts with the rule, since a proof of loss requirement must be reasonable and consider the claim's circumstances.

Utah Admin. Code r. 590-192-6(2)(b) says a proof of loss requirement may not be unreasonable and must take into account the circumstances surrounding the given claim. A fixed package demanded in every case, with no allowance for a claimant who spent weeks in intensive care, does not consider those circumstances. Policy terms are one measure of timely proof, but subsection (2)(a) also measures proof against the rule itself, which carries this reasonableness standard. The rule's consistency requirement concerns how an insurer accepts notice of loss, not a uniform proof package, and the rule defines proof of loss as the claimant's reasonable documentation, so some documentation may be required.

Answer: A. As an adverse benefit determination on the insured's claim

Utah's rule states that reducing or terminating concurrent care during treatment is an adverse benefit determination. The rule defines concurrent care as a course of treatment the insurer approves over a specific period or number of treatments, which describes the 12 approved sessions. Because the decision is an adverse benefit determination, the same section requires the insurer to give notice before the reduction or termination occurs, with enough time for the claimant to appeal and receive a decision. The rule does not label this decision a rescission of coverage, a new pre-service claim, or an administrative change outside the benefit determination process.

Answer: A. The commissioner must waive the examination requirement

Utah Code Ann. Sec. 31A-23a-108(2) directs the commissioner to waive the examination for an applicant who applies for a producer license within 90 days of establishing legal residence in Utah, has been licensed for the same line of authority in another state, and is licensed there when applying. She applied at 60 days and holds an Idaho license in force for the same lines, so the waiver is required rather than discretionary, and she does not have to sit for the Utah examination. The window is 90 days, not 30.

Answer: A. Electronically through Sircon, the one system the rule allows for this application

Rule R590-244-7 sends most new license applications through either Sircon or NIPR, but subsection (1) carves out navigator licenses, which must be submitted using Sircon. The Sircon-or-NIPR choice is the general rule for other new applications, not for a navigator. Facsimile or PDF email submission is the route the same rule gives a nonresident applying for a license type or line of authority not offered in the applicant's home state. A mailed paper application is not a method the rule provides for a new license.

Answer: B. 48 hours

On an urgent care claim, Utah's rule requires the insurer to give the claimant a reasonable time to provide missing information, and that time may be no shorter than 48 hours. Twenty-four hours is the insurer's own deadline, measured from receipt of the claim, for telling the claimant what information is required; it is not the claimant's response window. Seventy-two hours is the outer limit for the insurer's decision on an urgent care claim, measured from receipt of the claim. The urgent care paragraph sets no five-day period for the claimant's response.

Answer: B. At least one license type and one line of authority under that type

Utah Code Ann. Sec. 31A-23a-103(1)(b) provides that a valid license includes at least one license type together with one line of authority that pertains to that type. Both pieces are required at once. A line of authority with no license type is incomplete. A license type with lines to be added later is also incomplete, because the provision pairs the type with a line when the license is valid. The statute pairs a type with a specific line rather than treating the type as covering every line.

Answer: C. 9 a.m. on Thursday

The insurer must decide as soon as possible and no later than 48 hours after the earlier of two moments: when it receives the requested information, or when the claimant's time to provide it runs out. The information arrived Tuesday at 9 a.m., before the Wednesday deadline, so the earlier moment is Tuesday at 9 a.m. and the outer limit is 48 hours later, Thursday at 9 a.m. A decision by Wednesday at 9 a.m. would comply, but it is not the latest permitted time; it is only 24 hours after the information arrived. Friday at 9 a.m. counts 48 hours from the end of the response window, which is the later of the two moments rather than the earlier. Saturday at 9 a.m. counts 72 hours from the end of the response window, a period this paragraph does not use.

Answer: A. She must apply as a new license applicant, since the reinstatement window has closed.

Rule R590-244-10(1) allows reinstatement of a license that has been inactive for one year or less after its expiration date, and subsection (2) provides that an inactive license not reinstated within one year of expiration may not be reinstated, leaving the person to apply as a new license applicant. Fourteen months is past that one-year limit. Completing the missing continuing education would be part of a timely reinstatement, but it cannot revive a license once the year has run. The rule's window is one year, not two. The Sircon or NIPR route in subsection (5)(b) applies to a reinstatement filed from 31 days to one year after expiration, so it is unavailable here.