LLQP Accident & Sickness · Component 4.2 · 10% of the exam
A critical illness claimant is asked for a specialist's report and diagnostic test results. This is because:
- AThe insurer doubts the treating physician's competence to make the diagnosis in question
- The contract pays only if the condition meets its own definition, which the evidence must establish
- CCritical illness claims are adjudicated by a panel of specialists appointed by the provincial regulator
- DThe insurer must confirm that the claimant's income has fallen as a result of the diagnosis
Correct answer: B) The contract pays only if the condition meets its own definition, which the evidence must establish
Critical illness is a defined-event product, so the clinical evidence is needed to show that the diagnosis matches the contractual wording rather than the everyday name of the condition.
Why the other options are wrong
- AThe request is about meeting the definition, not about the doctor's competence.
- CThe insurer adjudicates the claim under its own contract.
- DCritical illness benefits do not depend on any loss of income.
Exam tip
The definition, not the diagnosis label, decides a CI claim.
Common mistake
Assuming a diagnosis letter alone will support a critical illness claim.
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.