CCA Medical Claims and Healthcare Coverage 3

Question 1

When reviewing a claimant's medical records, an adjuster should pay particular attention to:

Accepted Answer

Gaps in treatment, pre-existing conditions, and the link between treatment and the claim event

Answer

The claimant's financial history and credit score

Answer

The treating physician's personal credentials and educational background only

Answer

The hospital's Joint Commission accreditation status

Question 2

What is 'medical cost containment' in claims management?

Accepted Answer

Strategies and programs to ensure medical expenses are reasonable, necessary, and properly billed

Answer

Refusing to pay any medical bills regardless of validity

Answer

Setting an absolute maximum payment cap for all medical claims

Answer

Requiring all claimants to use only insurer-designated physicians

Question 3

In the context of bodily injury claims, 'pain and suffering' damages represent:

Accepted Answer

Non-economic damages for physical pain, emotional distress, and reduced quality of life

Answer

The cost of pain medication and physical therapy sessions

Answer

Lost wages due to inability to work because of ongoing pain

Answer

The projected cost of future medical treatment for chronic pain

Question 4

What is an ERISA lien in the context of personal injury claims?

Accepted Answer

A claim by an employer-sponsored health plan to recover benefits paid for injury-related treatment from a settlement

Answer

A lien filed by the state employment security agency

Answer

A federal court order freezing settlement funds pending resolution

Answer

A lien for unpaid workers' compensation insurance premiums

Question 5

What does 'subrogation' mean specifically in the context of medical claims?

Accepted Answer

The insurer's right to pursue recovery from a responsible third party after paying medical benefits

Answer

The claimant's right to substitute one treating physician for another

Answer

A formal process for appealing denied medical claims

Answer

The transfer of medical records between treating providers

Question 6

When evaluating future medical expenses in a serious injury claim, which factor is most important?

Accepted Answer

The nature of the injury and evidence-based projections of future treatment needs and associated costs

Answer

The claimant's current income and earning capacity

Answer

The insurance policy's next renewal date

Answer

The adjuster's personal experience handling similar prior claims

Question 7

A 'structured settlement' in a medical injury claim is best described as:

Accepted Answer

Periodic tax-free payments made over time rather than a single lump sum, often used in serious injury cases

Answer

A lump-sum payment made to the claimant immediately upon settlement

Answer

A payment plan allowing the claimant to pay their own medical bills over time

Answer

A court-mandated payment schedule for workers' compensation benefits