1.5 The Twelve Mandatory Uniform Policy Provisions
Key Takeaways
- The Uniform Individual Accident and Sickness Policy Provisions Law (UPPL), NAIC Model MO-180, requires every individual A&H policy to contain twelve standard provisions.
- Notice of claim is due within 20 days, claim forms must be furnished within 15 days, and proof of loss is due within 90 days (up to one year if not reasonably possible).
- Time Limit on Certain Defenses closes the door on non-fraudulent application misstatements after three years; fraud is never protected.
- Time of Payment of Claims requires immediate payment on receipt of due proof of loss, with periodic (disability) benefits paid at least monthly.
- Legal Actions bars suit for 60 days after proof of loss is filed and bars it entirely after three years.
Why One Section Carries So Much Weight
On the national content outline, Policy Provisions, Clauses, and Riders is worth roughly 30% of the general-knowledge portion — second only to Types of Policies. Most of that weight sits on a single body of law: the Uniform Individual Accident and Sickness Policy Provisions Law (UPPL), published by the NAIC as Model Law MO-180 and adopted in substance by essentially every state.
The UPPL does something unusual. It does not merely say "a policy must address reinstatement." It prints the exact wording the insurer must use, or wording the commissioner approves that is no less favorable to the insured. That is why these provisions are identical across carriers and why the exam can ask about them as pure recall. The twelve provisions below are mandatory — they appear in every individual A&H policy whether the insurer wants them or not.
The Twelve Mandatory Provisions
| # | Provision | The rule the exam tests |
|---|---|---|
| 1 | Entire Contract; Changes | The policy, endorsements, and attached application are the whole agreement. No change is valid unless approved by an executive officer of the insurer and endorsed on or attached to the policy. No agent can change the policy or waive a provision. |
| 2 | Time Limit on Certain Defenses | After 3 years from issue, non-fraudulent misstatements in the application cannot be used to void the policy or deny a claim. Fraudulent misstatements are never protected. This is the health analogue of life insurance's incontestable clause. |
| 3 | Grace Period | A period after the premium due date during which the policy stays in force: 7 days weekly-premium, 10 days monthly-premium, 31 days all others. |
| 4 | Reinstatement | If the insurer accepts a late premium without requiring an application, the policy reinstates immediately. If it requires an application and issues a conditional receipt, the policy reinstates on approval, or automatically on the 45th day absent written disapproval. A reinstated policy covers accidents immediately but sickness only after 10 days — an anti-selection guard, and the single most-tested detail in the provision. |
| 5 | Notice of Claim | Written notice within 20 days of the loss, or as soon as reasonably possible. |
| 6 | Claim Forms | The insurer must furnish proof-of-loss forms within 15 days of receiving notice. If it does not, the claimant may submit proof in any written form describing the occurrence, character, and extent of loss. |
| 7 | Proofs of Loss | Written proof within 90 days of the loss (or of the end of the period the insurer is liable for, on periodic benefits). Late proof does not defeat the claim if it was not reasonably possible to comply — but in no event later than one year, absent legal incapacity. |
| 8 | Time of Payment of Claims | Lump-sum benefits are paid immediately on receipt of due written proof. Periodic (disability) benefits are paid at stated intervals, not less frequently than monthly, with any balance paid immediately when liability ends. |
| 9 | Payment of Claims | Death benefits go to the beneficiary, or to the insured's estate if no valid designation exists. All other benefits go to the insured. An optional facility-of-payment clause lets the insurer pay a relative up to a small stated amount (commonly $1,000) when the payee is a minor or an estate. |
| 10 | Physical Examinations and Autopsy | The insurer may examine the insured at its own expense as often as reasonably necessary while a claim is pending, and may order an autopsy where not forbidden by law. |
| 11 | Legal Actions | The insured may not sue until 60 days after proof of loss is filed, and may not sue after 3 years from the date proof was required. |
| 12 | Change of Beneficiary | The insured may change the beneficiary at will — without the beneficiary's consent — unless the designation was made irrevocable. |
Reading the Timeline the Way the Exam Does
Almost every UPPL question is really a timeline question. Lay the claim provisions end to end:
Loss occurs → 20 days: notice of claim → insurer has 15 days to send forms → 90 days: proof of loss (1 year outside limit) → immediately: payment of a lump-sum claim → 60 days must pass before suit → 3 years: suit is time-barred.
A classic item gives you a date of loss and asks what the insured must do next, or gives you an insurer that never sent forms and asks whether the claim survives. It does: the Claim Forms provision converts the insurer's 15-day failure into permission for the claimant to write their own proof.
Worked example
Marisol is hospitalized on March 1. She notifies her insurer on March 15 — within the 20-day window, so notice is timely. The insurer never sends proof-of-loss forms. On May 20 she mails a letter describing the hospitalization, the dates, and the charges. That is 80 days after the loss, inside the 90-day proof window, and because no forms arrived within 15 days her letter satisfies the proof requirement. The insurer denies the claim on June 10. She may not file suit until 60 days after May 20, and she loses the right to sue after three years from the date proof was due.
Two Provisions People Confuse
Time Limit on Certain Defenses vs. Legal Actions. Both mention three years, and both are about closing doors — but in opposite directions. Time Limit on Certain Defenses closes the insurer's door: after three years it can no longer rescind for an innocent application misstatement. Legal Actions closes the insured's door: three years after proof was due, no lawsuit.
Entire Contract vs. Reinstatement. Entire Contract is about who may alter the agreement (an executive officer, in writing — never the agent). Reinstatement is about restoring a lapsed policy, and its 10-day sickness delay exists so a person who feels a cold coming on cannot pay up and claim the next morning.
Under the mandatory Reinstatement provision, when does coverage for sickness resume on a reinstated individual A&H policy?
An insured suffers a covered loss and gives timely notice of claim. The insurer never sends proof-of-loss forms. What is the effect?
How soon after filing proof of loss may an insured bring legal action against the insurer, and what is the outside deadline?
Four years after issue, an insurer discovers that an applicant innocently understated a prior back condition on the application. Under the Time Limit on Certain Defenses provision, what may the insurer do?
A producer tells an insured that an excluded procedure will be covered and writes the promise in the agent's file. Under the Entire Contract provision, what changes the policy?