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

Gaps in treatment may suggest the injury was minor, pre-existing conditions affect causation analysis, and treatment consistency with the claimed injury validates the claim's legitimacy and scope.

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

Medical cost containment encompasses utilization review, bill auditing, preferred provider networks, and similar strategies designed to ensure appropriate and cost-effective medical care is delivered and billed correctly.

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

Pain and suffering are non-economic general damages compensating claimants for the physical and emotional impact of injuries beyond objectively measurable financial losses such as medical bills or lost wages.

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

ERISA (Employee Retirement Income Security Act) liens allow employer-sponsored health plans to seek reimbursement from personal injury settlements for medical benefits they paid on behalf of the injured employee.

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

Subrogation allows an insurer that paid medical benefits to stand in the claimant's place and seek reimbursement from the at-fault third party or their insurer for amounts already paid.

(CCA) Certified Claims Adjuster Practice Test

(CCA) Certified Claims Adjuster Practice Test

CCA Medical Claims and Healthcare Coverage 3