11.1 Required and Optional Uniform Provisions

The Uniform Individual Accident and Sickness Policy Provisions Law (UPPL)

Every individual health policy must include a standard set of clauses drawn from the Uniform Individual Accident and Sickness Policy Provisions Law (UPPL), adopted in some form by all states. The law splits provisions into two groups: eleven mandatory (required) provisions that must appear in substantially the prescribed wording, and eleven optional provisions the insurer may include at its discretion. The exam tests both the function of each clause and the time frames embedded in them, because candidates frequently confuse the deadlines.

The eleven required provisions

Insurers may use language more favorable to the insured than the model, but never less favorable. The required provisions are:

Reading the time frames as a workflow

Line the claim deadlines up in sequence and they stop blurring together. A loss occurs; the insured has 20 days to give Notice of Claim. The insurer then has 15 days to supply Claim Forms. The insured files Proof of Loss within 90 days (courts allow up to one year if filing within 90 days was not reasonably possible). No lawsuit may be brought sooner than 60 days after proof, nor later than 3 years.

Trap: the Reinstatement clause covers accidents on the date of reinstatement but covers sickness only if it begins more than 10 days after the reinstatement date, blocking adverse selection.

The optional provisions

The optional provisions let the insurer protect itself; they are not in every policy. The two most heavily tested are:

• Change of Occupation — if the insured moves to a more hazardous job, benefits are reduced to what the premium paid would have bought at the riskier classification; a less hazardous job triggers a premium refund.
• Misstatement of Age — benefits are adjusted to what the premium would have purchased at the correct age. No contestability question arises; the policy simply re-rates.

Others include Illegal Occupation, Intoxicants and Narcotics, Other Insurance in This Insurer, Insurance with Other Insurers, Relation of Earnings to Insurance, Unpaid Premium, Conformity with State Statutes, and Cancellation.

Worked grace-period and contestability examples

Grace periods scale to how often premium is collected. A weekly-premium policy gives 7 days, a monthly-premium policy 10 days, and all others (quarterly, semiannual, annual) 31 days. If a monthly premium is due January 1 and the insured pays January 9, the policy never lapses because payment fell inside the 10-day grace window, and any covered claim during that span is paid.

The Time Limit on Certain Defenses mirrors life insurance incontestability: after the policy has been in force 2 years (3 in some states), the insurer cannot void it for misstatements in the application except for fraudulent ones, and cannot deny a claim because a non-excluded condition existed before issue.

Why the wording matters on exam day

Candidates lose points by treating these clauses as interchangeable. The Entire Contract provision means an agent's oral promise is worthless — only the written policy and attached application control, and only an executive officer can amend it. The Legal Actions provision creates a window, not a single date: a suit is barred before 60 days after proof of loss and after 3 years from proof. The Physical Examination and Autopsy clause is the insurer's own-expense right, exercised as often as reasonably required while a claim is pending, where state law allows.

The Uniform Individual Accident & Sickness Provisions

State law (from the NAIC model) splits individual health policy provisions into 12 required (mandatory) and 11 optional Uniform Provisions. The most-tested required provisions:

• Entire contract — the policy plus attached application is the whole contract; no changes without the insured's written consent.
• Time limit on certain defenses (incontestability) — after the policy has been in force 2 years (3 in some states), the insurer cannot void it or deny a claim for misstatements (except fraud) or for pre-existing conditions not excluded by name.
• Grace period — 7 days (weekly premium), 10 days (monthly), 31 days (other) to pay an overdue premium without lapse.
• Reinstatement — if a lapsed policy is reinstated, accidental coverage is immediate but sickness coverage has a 10-day waiting period to prevent adverse selection.
• Notice of claim (20 days), claim forms (15 days), proof of loss (90 days), and time/payment of claims.
• Physical exam and autopsy — the insurer may examine the insured and order an autopsy where not prohibited by law.
• Legal actions — the insured may not sue for 60 days after proof of loss, and not after 3 years.

Worked Timeline Example

An insured is injured Jan 1. Notice of claim is due within 20 days (~Jan 21); the insurer must furnish claim forms within 15 days of that notice; proof of loss is due within 90 days of the loss (~April 1). If the insurer fails to send claim forms, the insured satisfies the requirement by submitting written proof of the nature and extent of the loss. The insured cannot file suit until 60 days after proof of loss and must do so within 3 years.

Selected Optional Provisions

Optional provisions an insurer may include: misstatement of age (benefits adjusted to what the premium would have bought at the correct age), other insurance with this insurer (caps stacking), unpaid premium (deducted from claim payment), and change of occupation (benefits adjusted if the insured moves to a more or less hazardous job). These let the insurer correct for underwriting facts discovered at claim time without rescinding coverage.