LLQP Accident & Sickness · Component 4.2 · 10% of the exam
A CI claim is filed for a heart attack; the insurer requests cardiac enzyme and ECG evidence. The claimant asks why a doctor's letter is not enough. The agent should explain:
- AThe claim has been denied, since a request for further evidence means the insurer has rejected the diagnosis
- The policy defines heart attack by clinical criteria, and the specialist's records normally contain the evidence
- CThe insurer is stalling, since a physician's letter confirming a heart attack is all the contract requires
- DCardiac enzymes are irrelevant, since the policy pays on the treating physician's diagnosis alone
Correct answer: B) The policy defines heart attack by clinical criteria, and the specialist's records normally contain the evidence
CI claims are definition-driven. The evidence request is standard.
Why the other options are wrong
- AThe request is not a denial.
- CIt is a contractual requirement.
- DEnzymes are part of the definition.
Exam tip
CI evidence = the criteria in the definition.
Common mistake
Telling a client a diagnosis letter alone triggers CI.
What this tests
CISRO competency component 4.2 — Provide customer service during the validity period of the coverage — which is weighted at 10% of the Accident & Sickness module. Written against the published curriculum.
More from component 4
- The agent's role in the claims process is to:
- A client with a non-cancellable DI policy stops paying premiums after a dispute with the insurer about a claim. The agent should warn that:
- When a client moves to another province, the agent should:
- A client asks to reduce the waiting period on his in-force disability policy. The agent should explain that the change:
- A client's disability policy lapsed six weeks ago for non-payment. The agent should:
- A client on claim asks whether she must keep paying premiums. The accurate answer depends on:
Practice the whole Accident & Sickness module
Timed sets weighted like the exam, and review of every question you miss. Free to start.