LLQP Accident & Sickness · Component 4.2 · 10% of the exam
An extended health claim is denied because the service was provided by an unregistered practitioner. The agent should:
- Explain the plan's provider requirements, check whether the practitioner qualifies and help appeal
- BAdvise the client to claim the expense under the disability policy instead of the health plan
- CTell the client the denial is final, since paramedical claims cannot be reconsidered by an insurer
- DSubmit the claim again unchanged, since insurers usually pay on a second submission
Correct answer: A) Explain the plan's provider requirements, check whether the practitioner qualifies and help appeal
Provider eligibility is a plan term rather than a judgment about the treatment, and clarifying the practitioner's registration often resolves the matter without a formal dispute.
Why the other options are wrong
- BA disability policy does not reimburse treatment expenses.
- CDenials are open to review through the insurer's own process.
- DAn identical resubmission does not address the reason for the denial.
Exam tip
Check the provider requirement before assuming the treatment is uncovered.
Common mistake
Accepting a paramedical denial without reading the eligibility rule.
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.