Get Legal Help Today
Secured with SHA-256 Encryption
UPDATED: Jul 16, 2021
It’s all about you. We want to help you make the right legal decisions.
We strive to help you make confident insurance and legal decisions. Finding trusted and reliable insurance quotes and legal advice should be easy. This doesn’t influence our content. Our opinions are our own.
Editorial Guidelines: We are a free online resource for anyone interested in learning more about legal topics and insurance. Our goal is to be an objective, third-party resource for everything legal and insurance related. We update our site regularly, and all content is reviewed by experts.
What follows is a discussion of the Non-Waiver provision of the model individual health insurance policy we are using for review.
| (Typical wording*):
Limitations, Exclusions and Non-Waiver (cont.)
In order for the Lifetime Policy Maximum per insured to increase beginning with the next calendar year, a formula must be applied that is based on the total amount of all billed charges incurred by all insureds under the policy during the current calendar year.
Subparagraph a. above simply makes it clear that using all billed charges for purposes of making this calculation under the lifetime policy maximum provision does not serve as an acceptance by your insurance company that it is liable for insurance benefits.. The billed charges are used solely for the purpose of the calculation. Determining insurance company liability for the charges is a totally separate and unrelated exercise. The company just wants to make sure you know that. It also wants you to know that if, by chance, it mistakenly assumes liability for some of those charges perhaps because it is considering all the charges for purposes of their calculation, this error by the company does not act as a waiver of its right to deny similar future charges.
Similarly, under subparagraph b. above, your insurance company wants you to know that any mistakes it makes in payment of the prescription drug benefit does not somehow act as a waiver of the company’s right in the future to apply all the provisions of the policy that exclude and limit coverage. Nor does the mistake somehow act to create coverage that otherwise would not exist under the policy’s terms or serve to limit the company’s ability to rely on all the provisions of the policy.
If this is confusing, rest assured, you’re not alone. These all kind of say the same thing. They just want to make sure you understand.
*Wording may vary from contract to contract and from state to state.