Pennsylvania accident and health policy provisions practice questions
Last updated
On the Pennsylvania Accident and Health exam (Series 16-02), section 3.0 Accident and Health Insurance Basics is 10% and section 4.0 Individual Accident and Health Insurance Policy Provisions is 13%. [1] Section 3.0 includes limited policies such as critical illness, common exclusions, preexisting conditions, and the Pennsylvania replacement rules. Section 4.0 lists the required provisions, the general (optional) provisions, and other provisions such as the free look, insuring clause, renewability, coinsurance and elimination period. [1]
Our Pennsylvania A&H flashcards already cover the required provisions, such as the time limit on defenses, grace period, claim deadlines and legal actions. This page covers the rest: the optional provisions, exclusions, replacement and policy form rules.
Optional provisions (Insurance Company Law, section 618(B))
If a policy includes these subjects, it must use the wording in the law or approved wording that is no less favorable to the insured. [2]
- Change of occupation: if the insured is hurt or gets sick after moving to a more hazardous occupation, the insurer pays only the portion of the benefits the premium paid would have bought at the rates for the more hazardous occupation. [2]
- Misstatement of age: "all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age." [2]
- Unpaid premium: when a claim is paid, any premium then due and unpaid may be deducted from it. [2]
- Conformity with state statutes: a provision in conflict with the statutes of the insured's state of residence on the effective date is amended to meet their minimum requirements. [2]
- Illegal occupation: no liability for a loss to which committing or attempting a felony, or working in an illegal occupation, contributed. [2]
- Intoxicants and narcotics: no liability for a loss caused by being intoxicated or under the influence of a narcotic, unless the narcotic was given on a physician's advice. [2]
Policy form rules (section 617(A))
A policy must state the entire premium and other considerations, show when coverage starts and ends, use type no smaller than ten point, and carry a form number in the lower left corner of the first page. A policy called "non-cancellable" must be automatically renewable until age sixty as long as premiums are paid. [2] The ten day right to examine notice must be printed on the face of the policy. [3]
Exclusions and preexisting conditions
Beyond the exclusions in section 618, the Department permits general exclusions such as war or active military duty, suicide or intentionally self-inflicted injury, injury or sickness covered by workers' compensation, aviation except as a fare paying passenger on a commercial airline, riot, cosmetic surgery unless needed because of covered sickness or injury, and normal pregnancy. [4] A policy must clearly disclose whether it covers preexisting conditions. [5]
Limited policies, outline of coverage and replacement
A specified disease policy of the expense type must have a deductible of no more than $250, an aggregate benefit limit of at least $5,000 and a benefit period of at least 2 years. [6] No policy may be delivered without an outline of coverage that comes with the policy or is given when the application is made. [7] Applications must ask whether the new coverage will replace other accident and health insurance in force. [8] When a sale involves replacement, an insurer other than a direct response insurer must give the applicant a notice at the time the application is completed and keep a signed copy. [9] The notice tells the applicant that the new policy gives 10 days after receipt to decide whether to keep it, and warns about preexisting conditions and waiting periods. [10]
Practice questions
1. An insured moved to a more hazardous occupation without telling the insurer and was then injured. Under the change of occupation provision, what does the insurer pay?
A. Nothing
B. The full benefit
C. The portion the premium paid would have bought at the rates for the more hazardous occupation
D. Half the benefit
Answer: C. (Insurance Company Law, section 618(B)(1)) [2]
2. A claim reveals the insured's age was misstated. How are benefits set?
Answer: At what the premium paid would have purchased at the correct age. (section 618(B)(2)) [2]
3. A claim is paid while a premium is due and unpaid. What may the insurer do?
Answer: Deduct the unpaid premium from the claim payment. (section 618(B)(7)) [2]
4. A policy is labeled "non-cancellable." What must it do?
Answer: Be automatically renewable until age sixty as long as the insured pays the required premiums. (section 617(A)(8)) [2]
5. Where on a Pennsylvania policy must the ten day right to examine notice appear?
Answer: Imprinted on the face of the policy, worded to give the insured the option of a full refund. (31 Pa. Code 89.73(a)) [3]
6. Which is a general exclusion the Department permits?
A. Any illness that starts in the first policy year
B. Injury covered by a workers' compensation law
C. All outpatient care
D. Any hospital stay over 3 days
Answer: B. (31 Pa. Code 88.84(1)(iii)) [4]
7. Can a Pennsylvania policy exclude aviation hazards for a fare paying passenger on a commercial airline?
Answer: No. The permitted aviation exclusion applies "except while flying as a fare-paying passenger on a commercial airline." (88.84(1)(v)) [4]
8. What is the highest deductible an expense type specified disease policy may have?
Answer: $250, with an aggregate limit of at least $5,000 and a benefit period of at least 2 years. (31 Pa. Code 88.169(a)) [6]
9. When must the outline of coverage be given?
Answer: With the policy, or at the time the application is made. (31 Pa. Code 88.181) [7]
10. An agent's sale will replace a client's current health policy. When must the replacement notice be given?
Answer: At the time the application is completed, with a signed copy kept by the insurer. (31 Pa. Code 88.102) [9]
Study tips for sections 3.0 and 4.0
- Split the provisions into two lists: the required ones (in our flashcards) and the optional ones on this page.
- For exclusion questions, look for the exception words, such as "except while flying as a fare-paying passenger."
- Remember the two "10 day" rules: the free look on the face of the policy, and the 10 day decision period described in the replacement notice.
Practice the full A&H exam with our Pennsylvania accident and health practice test.
Prep Retention is independent and is not affiliated with PSI or the state.
Sources
Laws and exam documents quoted as of October 2026.
- PSI, Pennsylvania Accident and Health outline, Series 16-02 (effective 3/1/2026): https://proctor2.psionline.com/media/programs/PAINS/16-02xx.pdf
- Insurance Company Law of 1921 (Act of May 17, 1921, P.L. 682, No. 284), Sections 617 and 618: https://www.palegis.us/statutes/unconsolidated/law-information/view-statute?iFrame=true&txtType=HTM&SessYr=1921&SessInd=0&ActNum=0284
- 31 Pa. Code 89.73: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter89/s89.73.html&d=reduce
- 31 Pa. Code 88.84: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.84.html&d=reduce
- 31 Pa. Code 88.51: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.51.html&d=reduce
- 31 Pa. Code 88.169: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.169.html&d=reduce
- 31 Pa. Code 88.181: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.181.html&d=reduce
- 31 Pa. Code 88.101: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.101.html&d=reduce
- 31 Pa. Code 88.102: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.102.html&d=reduce
- 31 Pa. Code 88.103: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/031/chapter88/s88.103.html&d=reduce