LLQP Accident & Sickness · Component 2.1 · 30% of the exam
An extended health plan's 'reasonable and customary' limit means the plan pays:
- Up to the prevailing rate for the service in the area, with any excess borne by the member
- BA flat amount per visit set by the insurer and published in the benefit booklet
- CWhatever the provider charges, since the plan has agreed to cover the service
- DOnly the amount the provincial health plan would have paid for the very same service
Correct answer: A) Up to the prevailing rate for the service in the area, with any excess borne by the member
The limit controls the plan's exposure to providers who charge above local norms, and the member is responsible for the difference even where the service itself is covered.
Why the other options are wrong
- BA flat per-visit amount would be a scheduled benefit, not a customary limit.
- CAn open-ended promise to match any charge is precisely what the limit prevents.
- DThe provincial rate is not the benchmark for a private plan's limit.
Exam tip
Covered does not mean paid in full.
Common mistake
Telling a member a covered service costs them nothing.
What this tests
CISRO competency component 2.1 — Analyze the available products that meet the client's needs — which is weighted at 30% of the Accident & Sickness module. Written against the published curriculum.
More from component 2
- A group benefits booklet lists AD&D coverage alongside life and LTD. The AD&D benefit pays:
- A hospital indemnity (hospital cash) policy pays:
- Employment Insurance sickness benefits are available to:
- Which government program coordinates with an individual DI policy through a possible offset AND also affects the definition of insurable income?
- A group plan's 'eligibility waiting period' (probationary period) is:
- A CI policy that is 'convertible' allows the insured to:
Practice the whole Accident & Sickness module
Timed sets weighted like the exam, and review of every question you miss. Free to start.