LLQP Accident & Sickness · Component 4.2 · 10% of the exam
A disability claim is denied and the claimant disagrees. The agent should explain that the next steps are:
- ANothing further, since the insurer's claims department has final authority over its own contracts
- BA complaint to the police, since a denied claim is a form of fraud against the policyholder
- Written reasons, an internal appeal with further evidence, then the ombudservice and the courts in time
- DImmediate court proceedings, since insurers rarely reverse a decision once it has been issued in writing
Correct answer: C) Written reasons, an internal appeal with further evidence, then the ombudservice and the courts in time
A structured escalation gives the claimant the best chance of a reversal and preserves the right to litigate, provided the limitation period is watched throughout.
Why the other options are wrong
- ADenials are routinely reconsidered on further evidence.
- BA claim decision is a contractual dispute, not a criminal matter.
- DLitigation is the last step, not the first.
Exam tip
Reasons, evidence, internal appeal, ombudservice, court.
Common mistake
Letting a denied claim sit until the limitation period expires.
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.