IC36 Mock Test Sample 12
Health Insurance Claims Management focuses on efficient claim processing, fraud prevention, provider management, and quality healthcare delivery. It involves coordination among insurers, TPAs, hospitals, and policyholders to ensure timely and fair claim settlement. Key aspects include monitoring provider behavior, conducting audits, analyzing claim trends, accrediting healthcare organizations through NABH, and ensuring compliance with underwriting guidelines. Primary care providers coordinate treatment pathways, while TPAs facilitate claim administration. Understanding medical specialties, ethical practices, documentation requirements, and fraud indicators helps improve customer service, control claim costs, and strengthen the overall health insurance ecosystem.
1. Which document is generally required in case of a Personal Accident death claim?
a) Original policy bond
b) Post-mortem report
c) Salary certificate
d) School leaving certificate
2. The primary care provider is responsible for:
a) Coordinating treatment
b) Referring patients when necessary
c) Advising relevant tests
d) All of the above
3. Providers should be monitored periodically for:
a) Claim count only
b) Claim amount only
c) Nature of claims only
d) Claim count, amount, and nature
4. Disorders related to the ureter are commonly managed under:
a) Endocrinology
b) Urosurgery
c) Gastroenterology
d) Cardiology
5. Which of the following is a non-medical benefit under Overseas Mediclaim Policy?
a) Trip delay cover
b) Hospital room rent
c) ICU expenses
d) Consultation charges
6. NABH primarily evaluates healthcare organizations for:
a) Age of establishment
b) Number of beds
c) Quality standards
d) Revenue generation
7. Claim surveillance reports help track:
a) Claim incidence rates
b) Claim patterns
c) Agent-wise claim ratios
d) All of the above
8. Which symptom may indicate endocrine system malfunction?
a) Weakness
b) Menstrual changes
c) Swelling
d) All of the above
9. Repatriation of mortal remains refers to:
a) Burial arrangements
b) Return of mortal remains
c) Hospital discharge
d) Claim repudiation
10. Contracting with providers helps in understanding:
a) Documentation requirements
b) Policy exclusions
c) Treatment processes under insurance
d) All of the above
11. Unethical practices leading to unnecessary healthcare costs are termed:
a) Fraud
b) Abuse
c) Negligence
d) Arbitration
12. The large intestine mainly functions to:
a) Produce digestive enzymes
b) Absorb excess water
c) Digest proteins
d) Store bile
13. Which document is usually submitted along with a consolidated hospital bill?
a) Passport copy
b) Admission notes
c) Electricity bill
d) Income certificate
14. Lack of clinical audits in the insurance industry primarily impacts:
a) Cost of care
b) Tourism industry
c) Transport sector
d) Agriculture sector
15. Agreeing to settle a claim for a lower amount despite eligibility may indicate:
a) Customer satisfaction
b) Fraud suspicion
c) Policy enhancement
d) Premium reduction
16. Third Party Administrators (TPAs) are licensed by:
a) State Governments
b) Hospitals
c) IRDAI
d) Consumer Forums
17. Review of historical clinical records is part of which audit type?
a) Concurrent audit
b) Infrastructure audit
c) Retrospective audit
d) Financial audit
18. Deliberately hiding a pre-existing illness to obtain lower premiums is classified as:
a) Internal fraud
b) Consumer fraud
c) Hard fraud
d) Technical fraud
19. Which factor is generally NOT considered during underwriting?
a) Past claim experience
b) Pricing considerations
c) Policy terms
d) Customer feedback ratings
20. The medical term "Glossitis" refers to inflammation of the:
a) Blood vessels
b) Stomach lining
c) Tongue
d) Urinary bladder
