State RegulationsNY specificDifficulty 2/5
An insured in Queens is injured while breaking into a warehouse and files an accident claim under his individual health policy. Under New York law, the insurer may
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under N.Y. Ins. Law §3216(d)(2)(J), benefits may be excluded for loss arising while the insured is committing or attempting a felony or engaged in an illegal occupation. An injury sustained during a burglary is exactly that, so the insurer may deny the claim. The time limit on certain defenses in §3216(d)(1)(B) bars contesting the policy based on pre-issue health; it does not neutralize an exclusion for loss occurring during criminal conduct.
Why the other options are wrong
- A) There is no pay-and-reimburse remedy; the loss itself is excluded.
- B) Incontestability does not legitimize losses excluded by the illegal occupation provision.
- D) The provision governs claim payment, not cancellation of the policy.
Memory hook
Felony in progress means the claim is out.