Indiana State Life and Health Insurance Practice Exam

If a health insurance claim is submitted but contains a discrepancy regarding the policyholder's health history, what can the insurer do?

1. Immediately approve the claim

2. Request additional information before processing

3. Pay the claim in full

4. Reject the claim outright

The correct answer is: Request additional information before processing

When a health insurance claim is submitted with a discrepancy regarding the policyholder's health history, the insurer can request additional information before processing the claim. This approach is important for ensuring the accuracy and validity of the claim. The insurer needs to verify all details related to the policyholder's health history to assess the legitimacy of the claim, which may involve discrepancies that could impact coverage or the cost of care. By requesting more information, the insurer conducts due diligence, allowing them to clarify any misunderstandings or inaccuracies that may have occurred. This step is crucial as it helps to protect both the insurer and the insured by ensuring that claims are paid based on accurate health history information. This process is a standard practice to maintain integrity and fairness in claims processing, as insurers have to comply with both their internal guidelines and regulatory requirements regarding the handling of claims.