LLQP Accident & Sickness · Component 4.2 · 10% of the exam
A claim is denied. The agent should:
- AAsk the treating physician to amend the medical records so that they support the claim more strongly
- Obtain written reasons, help with evidence or an internal appeal, and explain OLHI and legal time limits
- CTell the claimant to give up, since insurers rarely reverse a denial once it has been issued in writing
- DAccept the denial as final, since the insurer's claims department has the authority to interpret the contract
Correct answer: B) Obtain written reasons, help with evidence or an internal appeal, and explain OLHI and legal time limits
Denials often stem from insufficient evidence or definition issues. The appeals route runs from insurer to the OmbudService for Life & Health Insurance (OLHI) and, ultimately, the courts within limitation periods.
Why the other options are wrong
- AAltering medical records is fraud and exposes both claimant and agent to prosecution.
- CAdvocacy is part of service.
- DDenials can be appealed.
Exam tip
Denial: reasons → evidence/appeal → OLHI → court within limitation period.
Common mistake
Missing the limitation period while appealing informally.
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.