IC36 Mock Test Sample 16
Third Party Administrators (TPAs) play a crucial role in health insurance by managing enrolment, claims processing, networking with hospitals, and grievance handling. Medical management focuses on restoring health through appropriate treatment, coordination of healthcare services, and ensuring quality care. Investigation outcomes help identify fraud, inflation, pre-existing diseases, or genuine claims. Fraud detection and strict claims management are essential to reduce financial losses and protect stakeholders. Package pricing, cost control measures, and empanelment of hospitals contribute to efficient healthcare delivery. Timely claim intimation, effective IT systems, and customer-centric grievance redressal strengthen the overall insurance ecosystem.
Q1. The enrolment information provided by insurers to TPAs generally includes all except:
a) Policy number and policy period
b) TPA name and customer name
c) Sum insured details
d) Extra coverage details
Q2. Medical Management refers to all except:
a) Management of health
b) Management of healthcare services
c) Management to restore health
d) Management of medicine costs for claim inclusion
Q3. Which of the following is NOT generally an outcome of investigation?
a) Fraud confirmed by records
b) Inflation confirmed by records
c) Rejection of policy
d) Claim proved genuine
Q4. Service intermediaries that share the burden of claim processing are known as:
a) Agents
b) Brokers
c) Channel Partners
d) Third Party Administrators
Q5. The word closest in meaning to 'curative action' is:
a) Corrective
b) Restorative
c) Penal
d) Rehabilitative
Q6. Retail Personal Accident Policy fraud may include:
a) Impersonation and fake death certificates
b) Fabricated permanent disability claims
c) Staged accidents in collusion
d) All of the above
Q7. Which tools can assist in Medical Management?
a) Checklists
b) Expert opinions
c) Prognostic care
d) All of the above
Q8. The word closest in meaning to 'perpetrated' is:
a) Surreptitious
b) Above-board
c) Forthright
d) Unauthorized
Q9. Which statement is incorrect regarding Case Management?
a) It adopts a client-centric approach
b) It focuses on individual needs
c) It promotes wellness and information sharing
d) It primarily reviews fraudulent claims
Q10. Identify the correct statement regarding Agents and Brokers:
a) Agents offer insurance policies only
b) Brokers provide advice only
c) Both agents and brokers can assist customers in claim servicing
d) Agents arrange quotes only
Q11. Which activity is NOT expected from TPAs?
a) Maintaining hospital directories
b) Negotiating package rates
c) Employing qualified medical professionals
d) Altering negotiated rates during treatment
Q12. For emergency hospitalization, claim intimation should generally be given within:
a) 7 days
b) 30 days
c) 15 days
d) 2 days
Q13. __________ forms the core of any TPA organization.
a) Finance
b) Claims
c) Networking
d) Information Technology
Q14. The word closest in meaning to 'miscreant' is:
a) Incorrect
b) Errant
c) Normal
d) Righteous
Q15. Which statement about fraud is incorrect?
a) Fraud is a wilful act
b) Fraud is deliberate
c) Fraud causes financial losses
d) Fraud is legal
Q16. Hospital package costs may include:
a) OT charges
b) Investigations under standard protocols
c) Medicines during hospitalization
d) All of the above
Q17. __________ is a process that uses tools to ensure health insurance costs remain justifiable to stakeholders.
a) Cost Control
b) Insurance Planning
c) Rate Negotiation
d) Treatment Planning
Q18. A Grievance Management System comprises:
a) Receipt and acknowledgment of grievances
b) Assignment to responsible personnel
c) Resolution and customer communication
d) All of the above
Q19. Traditional Health Insurance Policies are policies of:
a) Trust
b) Illness
c) Indemnity
d) Specific Illness
Q20. The process of entering into an agreement with hospitals to provide cashless services is termed as:
a) Concordat
b) Commitment
c) Arrangement
d) Empanelment
