IC36 Mock Test Sample 3
IC36 Health Insurance Claims Management covers hospitalization claims, TPA functions, medical management, cost control, and policy administration. TPAs facilitate cashless services, data management, and customer support. Health insurance generally covers pre-hospitalization, hospitalization, and post-hospitalization expenses related to the same illness. Concepts such as gatekeeping, case management, preventive care, and provider selection help control claim costs. Understanding human anatomy, common diseases, day care procedures, and medical terminology is important for accurate claims assessment. Proper underwriting, documentation, discharge formalities, and awareness of policy conditions ensure efficient claim processing and improved customer satisfaction.
1. Which statement regarding health insurance claims is correct?
a) Pre-hospitalization expenses are never covered
b) Claims generally arise upon hospitalization of the insured
c) Only post-hospitalization expenses are covered
d) Health insurance does not cover hospitalization expenses
2. The primary objective of Third Party Administrators (TPAs) is to:
a) Facilitate customer service in health insurance
b) Organize cashless treatment facilities
c) Support fair and prompt claim settlement
d) Increase premium collection
3. Which is the correct sequence in medical management?
a) Clinical Assessment → Diagnostic Procedures → Treatment Plans → Monitoring
b) Monitoring → Treatment Plans → Diagnostic Procedures → Clinical Assessment
c) Treatment Plans → Clinical Assessment → Monitoring → Follow-up
d) Diagnostic Procedures → Monitoring → Clinical Assessment → Treatment Plans
4. Ovarian cysts and tumors are associated with which body system?
a) Digestive System
b) Reproductive System
c) Cardiovascular System
d) Nervous System
5. Pre and post-hospitalization expenses should relate to the same:
a) Treatment provider
b) Hospitalization event
c) Ailment
d) Policy period
6. The TPA concept was introduced mainly to:
a) Reduce premiums
b) Assist insurers in managing health claims
c) Eliminate underwriting
d) Increase policy sales only
7. Gatekeeping in health insurance refers to:
a) Restricting access to inappropriate healthcare utilization
b) Closing hospitals during emergencies
c) Preventing policy issuance
d) Limiting cashless claims
8. Which gland secretes hormones that regulate glucose utilization?
a) Thyroid Gland
b) Pituitary Gland
c) Pancreas
d) Adrenal Gland
9. The requirement of minimum beds and facilities in a hospital helps ensure:
a) Better premium pricing
b) Genuine hospitalization services
c) Faster claim payments
d) Higher claim amounts
10. To utilize cashless facilities effectively, policyholders should:
a) Carry TPA cards and policy documents
b) Verify network hospital status
c) Provide accurate pre-authorization details
d) All of the above
11. Hepatitis transmitted through infected blood and needles is commonly caused by:
a) Hepatitis A
b) Hepatitis B
c) Hepatitis E
d) Hepatitis D
12. Domiciliary hospitalization claims are generally payable when there is no:
a) Qualified doctor
b) Accommodation available in hospitals
c) Nursing staff
d) Operation theatre
13. External reports are used by insurers to:
a) Analyze loss trends
b) Update claim reserves
c) Monitor policy performance
d) All of the above
14. Proper scrutiny of proposals before underwriting helps to:
a) Assess risks accurately
b) Build a sound insurance portfolio
c) Reduce undue claims
d) All of the above
15. One reason for limited implementation of case management is:
a) High operational costs
b) Customer non-disclosure
c) Resistance from healthcare providers
d) All of the above
16. Influenza is best described as:
a) A bacterial infection affecting the lungs
b) A viral infection affecting the respiratory system
c) A fungal disease affecting the throat
d) An autoimmune disorder affecting the bronchi
17. Cataract surgery requiring only a few hours of hospitalization is considered:
a) A non-payable claim
b) An outpatient treatment
c) A day care procedure
d) A domiciliary treatment
18. At the time of final discharge, patients may be required to:
a) Pay non-admissible expenses
b) Sign claim-related documents
c) Complete required formalities
d) All of the above
19. The word closest in meaning to "eases" is:
a) Restricts
b) Facilitates
c) Complicates
d) Delays
20. Gingivitis refers to:
a) Inflammation of the lungs
b) Inflammation of the gums
c) Infection of the skin
d) Inflammation of the tonsils
