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| Section | Objectives |
|---|---|
| Accident and Health Insurance | - Health insurance products
|
| Insurance Fundamentals | - Principles of insurance and risk management
|
| State Regulations (New York) | - Ethics and compliance
|
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NEW QUESTION # 86
Under Workers ' Compensation, injured employees are covered for all of the following losses EXCEPT
Answer: D
Explanation:
Workers' Compensation is a form of insurance that provides benefits to employees who suffer work-related injuries or occupational illnesses . It is designed as a no-fault system , meaning employees receive benefits regardless of who caused the accident, while employers are generally protected from lawsuits related to workplace injuries. Workers' Compensation typically provides several types of benefits, including payment of necessary medical expenses , replacement of a portion of lost wages , and coverage for occupational illnesses or diseases that arise from employment conditions. In cases of severe injury or death, additional disability or survivor benefits may also be provided.
However, Workers' Compensation does not provide benefits for pain and suffering . Compensation for emotional distress or general suffering is usually associated with civil liability lawsuits, not with Workers' Compensation benefits. The system focuses primarily on economic losses -such as medical costs and lost income-rather than non-economic damages. Because of this trade-off, employees receive quicker access to benefits without needing to prove employer negligence, but they also give up the right to sue the employer for additional damages like pain and suffering.
NEW QUESTION # 87
Which type of life insurance policy is written under a single contract for both spouses in which it is payable upon the first death?
Answer: A
Explanation:
The correct answer is C. Joint. A joint life insurance policy insures two individuals-most commonly spouses-under one single contract , with the death benefit paid when the first insured person dies . This arrangement is commonly referred to as "first-to-die" coverage . Once the death benefit is paid following the first insured's death, the policy typically terminates because the contract has fulfilled its purpose. Joint life policies are often used in family financial planning when funds are needed immediately after the first spouse dies to cover expenses such as income replacement, debts, or final expenses.
This differs from survivorship life insurance , also known as second-to-die insurance , where the policy insures two people but the death benefit is paid only after the second insured dies . Survivorship policies are commonly used for estate planning or wealth transfer strategies. The other options are incorrect because dual capacity is not a standard life insurance policy type, and spousal is not the technical term used in life insurance contracts for a first-to-die policy. Therefore, a life insurance policy covering both spouses under one contract with payment at the first death is known as joint life insurance .
NEW QUESTION # 88
When a provider does NOT have an agreement with the insurer for payment, they will be reimbursed
Answer: D
Explanation:
When a medical provider does not have a contract or payment agreement with an insurer (often called a nonparticipating or out-of-network provider), the insurer generally does not pay based on a negotiated contract rate. Instead, reimbursement is commonly determined using a UCR methodology- Usual, Customary, and Reasonable charges. "Usual" refers to the typical charge a provider makes for a service;
"customary" reflects what providers in the same geographic area commonly charge for that service; and
"reasonable" considers whether the charge is appropriate given the circumstances and local market norms.
Under many major medical plans, the insurer pays a percentage of the UCR amount (subject to deductibles and coinsurance), and the patient may be responsible for any difference between the provider's billed charge and the insurer's allowed UCR amount (often referred to as balance billing , where permitted).
The other choices do not match standard insurer payment terminology: "absolute" and "relative" fee are not the typical reimbursement basis described for noncontracted providers, and "non-scheduled plan customary fee" is not the recognized standard method used in these plan provisions.
NEW QUESTION # 89
Which of the following is described when a selected group of practitioners, in a certain area, agrees to provide services at a pre-arranged cost on a fee-for-service basis?
Answer: C
Explanation:
The correct answer is A. preferred provider organization. A Preferred Provider Organization (PPO) is a health care arrangement in which an insurer or plan contracts with a selected network of doctors, hospitals, and other providers in a geographic area to deliver medical services at negotiated or reduced charges . Federal and New York sources describe PPOs as networks of participating providers that agree to furnish care at discounted rates, while patients generally retain the flexibility to use non-network providers at a higher cost. That matches the question's description of a selected group of practitioners agreeing to provide services at a pre- arranged cost on a fee-for-service basis . ( HealthCare.gov ) The other options do not fit this definition. An indemnity organization traditionally reimburses covered losses and does not depend on a contracted provider network with prearranged fees. A risk purchasing group is associated with liability insurance purchasing arrangements, not standard health provider networks. Coalition group is not the recognized term for this managed care structure. Therefore, the correct description is a preferred provider organization . ( Department of Financial Services )
NEW QUESTION # 90
Which of the following statements BEST describes a disability elimination period?
Answer: C
NEW QUESTION # 91
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