State RegulationsNC specificDifficulty 2/5
A Raleigh resident buys an individual accident and health policy containing a preexisting condition exclusion. Under North Carolina law, the exclusion may be based on advice, diagnosis, care, or treatment that the insured received or was recommended during which period before the policy's effective date?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under G.S. 58-51-15(a)(2)b, a preexisting condition exclusion may not extend beyond 12 months after the policy's effective date, and the look-back is limited to advice, diagnosis, care, or treatment received or recommended during the 1-year period immediately preceding the effective date. Conditions first arising or treated earlier than that window cannot support the exclusion, and credit for prior credible coverage applies under G.S. 58-51-17.
Why the other options are wrong
- A: A 3-year look-back exceeds the statutory cap; only the 1-year period before the effective date may be examined under G.S. 58-51-15(a)(2)b.
- B: A 2-year look-back likewise exceeds the limit fixed by G.S. 58-51-15(a)(2)b, which confines the review window to one year.
- D: The look-back is capped — the insurer cannot reach back without limit; only care or advice within the 1-year window before the effective date counts (G.S. 58-51-15(a)(2)b).
Memory hook
Preexisting: 1-year look-back, 12-month exclusion cap.