An individual accident and health policy issued in Rochester has been in force for more than 2 years. The insured submits a claim for a condition that existed before the policy's effective date but was never excluded from coverage by name or specific description. The insurer denies the claim solely because the condition predated the policy. Under N.Y. Ins. Law §3216(d)(1)(B), the denial is:

Why D is correct

Under N.Y. Ins. Law §3216(d)(1)(B), no claim for loss incurred or disability commencing after 2 years from the date of issue may be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss existed before the effective date of coverage. Because the condition was never named or specifically excluded, the denial of a claim after the 2-year period is improper.

Why the other options are wrong

• A) Conditions may be excluded by name or specific description, but an unnamed, undescribed preexisting condition cannot support denial of a claim after 2 years.
• B) The insurer has no free-floating option to exclude predated conditions; only those excluded by name or specific description may be used after the 2-year period.
• C) Preexisting conditions can be excluded when named or specifically described; the protection applies only to conditions not excluded in that way.

Memory hook

After 2 years: never named or described as excluded means covered.