Life & Health Insurance Exam Claims and Benefits 2 — Questions and Answers
Question 1: Under the 'proof of loss' provision, how many days does a health insured typically have to submit proof of loss after a claim?
- 30 days
- 60 days
- 90 days (Correct answer)
- 120 days
Correct answer: 90 days
Most health insurance policies require the insured to submit written proof of loss within 90 days of the loss.
Question 2: A life insurer discovers that an insured misrepresented their age on the application. What will the insurer most likely do?
- Void the policy and pay nothing
- Adjust the benefit to what the correct premium would have purchased (Correct answer)
- Pay the full face amount without adjustment
- Cancel the policy and return all premiums
Correct answer: Adjust the benefit to what the correct premium would have purchased
When age is misstated, insurers adjust the death benefit to the amount the actual premium would have purchased at the correct age rather than voiding the policy.
Question 3: Which type of health insurance claim is filed directly by the provider to the insurer on behalf of the patient?
- Indemnity claim
- Assignment of benefits claim (Correct answer)
- Subrogation claim
- Coordination of benefits claim
Correct answer: Assignment of benefits claim
When a patient assigns benefits to the provider, the provider submits the claim and receives payment directly from the insurer.
Question 4: What is 'subrogation' in the context of health insurance?
- The insurer's right to recover claim payments from a liable third party (Correct answer)
- The insured's right to appeal denied claims
- A method of splitting premiums between employer and employee
- A process for coordinating benefits between two insurers
Correct answer: The insurer's right to recover claim payments from a liable third party
Subrogation allows the insurer to recover amounts paid on a claim from a third party who was legally responsible for the loss.
Question 5: A disability income policy's 'elimination period' functions most like which feature of other insurance policies?
- Grace period
- Deductible (Correct answer)
- Coinsurance
- Co-payment
Correct answer: Deductible
The elimination period is a waiting period before benefits begin, functionally similar to a time-based deductible.
Question 6: Under the 'physical examination and autopsy' provision, who bears the cost of the examination requested by the insurer?
- The insured or beneficiary
- The insurer (Correct answer)
- The attending physician
- Medicare
Correct answer: The insurer
The insurer pays for any physical examination or autopsy it requires during a pending claim investigation.
Life & Health Insurance Exam Claims and Benefits 2
Under the 'proof of loss' provision, how many days does a health insured typically have to submit proof of loss after a claim?