CALA CALA Medical Claims & Bodily Injury 1 — Questions and Answers
Question 1: What is the primary purpose of obtaining medical authorizations (HIPAA releases) during a bodily injury claim investigation?
- To access the claimant's medical records relevant to the injury claimed (Correct answer)
- To authorize the insurer to perform surgery
- To waive the claimant's right to future treatment
- To transfer the claim to a health insurer
Correct answer: To access the claimant's medical records relevant to the injury claimed
A HIPAA-compliant medical authorization allows the adjuster to obtain medical records necessary to evaluate the nature and extent of the claimant's injuries.
Question 2: What does the term 'causation' mean in the context of a bodily injury claim?
- Whether the claimed injury was caused by the insured accident (Correct answer)
- The total dollar amount of medical bills
- The claimant's pre-existing health conditions
- The type of insurance policy in force
Correct answer: Whether the claimed injury was caused by the insured accident
Causation establishes the legal and medical link between the accident and the claimed injuries, which is essential for determining the insurer's liability.
Question 3: Which type of damages compensates a bodily injury claimant for physical pain and emotional distress?
- General (non-economic) damages (Correct answer)
- Special (economic) damages
- Punitive damages
- Nominal damages
Correct answer: General (non-economic) damages
General damages cover intangible losses like pain, suffering, and emotional distress that are not easily quantified by bills or receipts.
Question 4: What are 'specials' in bodily injury claims terminology?
- Quantifiable economic losses such as medical bills and lost wages (Correct answer)
- Secret settlement amounts
- Special policy endorsements
- Specialty medical procedures only
Correct answer: Quantifiable economic losses such as medical bills and lost wages
In bodily injury claims, 'specials' refer to special (economic) damages that can be documented with receipts, including medical expenses and lost income.
Question 5: An independent medical examination (IME) is typically requested by an insurer for what purpose?
- To obtain an objective physician's opinion on the nature, extent, and causation of injuries (Correct answer)
- To replace the claimant's treating physician
- To authorize additional surgery at the insurer's expense
- To deny all future medical treatment automatically
Correct answer: To obtain an objective physician's opinion on the nature, extent, and causation of injuries
An IME provides an independent medical assessment that helps the insurer evaluate whether claimed injuries and treatment are causally related to the accident.
Question 6: Which factor most significantly affects the settlement value of a soft-tissue bodily injury claim?
- Duration of treatment and documented medical expenses (Correct answer)
- The color of the vehicle involved
- Whether the insured has a prior traffic citation
- The deductible amount on the policy
Correct answer: Duration of treatment and documented medical expenses
For soft-tissue injuries, the length and cost of medical treatment are the primary drivers of settlement value since there are no objective diagnostic findings like fractures.
CALA CALA Medical Claims & Bodily Injury 1
What is the primary purpose of obtaining medical authorizations (HIPAA releases) during a bodily injury claim investigation?