Long Term Care Certification Practice Test

What is likely to happen if a person is involved in a second claim for the same condition shortly after being discharged?

1. They will be entitled to full benefits

2. The claim may be denied based on policy exclusions

3. The claim will automatically be approved

4. The policy will merely lapse

The correct answer is: The claim may be denied based on policy exclusions

If a person is involved in a second claim for the same condition shortly after being discharged, it is likely that the claim may be denied based on policy exclusions. Insurance policies often have specific clauses that limit or exclude benefits for pre-existing conditions or for conditions that have been recently treated. These clauses are intended to prevent what is known as "moral hazard," where the insured might seek unnecessary treatment or care due to the insurance coverage. In the context of long-term care insurance, it is important to understand the terms of the policy regarding how often and under what circumstances benefits can be claimed. If the second claim closely follows the discharge from care for the same condition, the insurer may view this as a continuation of the same issue rather than a new, qualifying condition. As a result, they may invoke policy exclusions that apply to the timing and nature of the claim. Understanding these policy details helps applicants and beneficiaries navigate their coverage more effectively, ensuring they are aware of potential limitations that may impact their claims.