LLQP Accident & Sickness · Component 1.2 · 35% of the exam
A client's group EHC plan has a coordination of benefits provision and her spouse has a plan too. For her own claims:
- AThe spouse's plan pays first because it was issued earlier
- Her own plan pays first, and her spouse's plan may pay the balance of the expense
- CBoth plans pay in full, so the family receives twice the eligible expense on every claim
- DNeither plan pays until the two insurers agree on the split, which can delay reimbursement for months
Correct answer: B) Her own plan pays first, and her spouse's plan may pay the balance of the expense
COB rules: the claimant's own plan is primary; the spouse's plan is secondary. Combined payment cannot exceed the eligible expense. Children follow the birthday rule.
Why the other options are wrong
- AThe claimant's own plan is primary; issue dates decide nothing for adults.
- CTotal reimbursement is capped at the eligible expense.
- DBoth plans participate in sequence; there is no deadlock.
Exam tip
COB: own plan first, spouse's second, birthday rule for children, no double recovery.
Common mistake
Submitting a claim to the spouse's plan first.
What this tests
CISRO competency component 1.2 — Assess the client's needs and situation — which is weighted at 35% of the Accident & Sickness module. Written against the published curriculum.
More from component 1
- The single most important fact for sizing a client's disability income need is:
- A client's beneficiaries for assets are listed in the fact-finding. Why does this matter for A&S planning?
- A client asks why the agent wants to know how assets are owned (jointly or individually). In the A&S context the answer is:
- A client mentions a back injury five years ago that fully resolved. The agent should:
- Which element of a client's situation most affects the definition of disability that should be recommended?
- Which of the following health facts is most relevant to a client's disability insurance situation?
Practice the whole Accident & Sickness module
Timed sets weighted like the exam, and review of every question you miss. Free to start.