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This quiz is meant to test your knowledge on dates and amounts for LTD and LW claim set up. Its purpose is to provide some insight into the current level of knowledge and effectiveness of past training received and whether there may be further training opportunities. It is not a pass and fail test, although it is graded. You must take the quiz at least once.
Questions and Answers
1.
Date of birth for the member is December 7, 1952. The contract indicates that LTD benefits are payable until the member attains age 65. The maximum benefit date would be:
A.
December 7, 2017
B.
December 31, 2017
C.
December 6, 2017
Correct Answer C. December 6, 2017
Explanation Benefits are paid up to age 65, December 6, 2017 unless the contract specifically states “up to and including age 65”.
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2.
The MS indicates that the LDW is August 18, and the PS had confirmed that LDW is August 19. The APS noted that the medical condition began August 17, and the first treatment date is August 21. The date disabled would be:
A.
August 19
B.
August 20
C.
August 22
Correct Answer B. August 20
Explanation August 20 would be used as the date disabled as the PS has confirmed August 19 as the LDW and the member’s condition had began prior to the LDW.
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3.
The policy provisions indicate that the maximum benefit date for LTD is the end of the month in which the member attains age 65. The member’s date of birth is February 29, 1948. The maximum benefit date would be:
A.
February 29, 2013
B.
February 28, 2013
C.
February 29, 2012
Correct Answer B. February 28, 2013
Explanation The member turns 65 that last day of the month in their 65th year. In this case since February is a leap month the maximum date would be February 28, 2013.
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4.
The MS indicates the LDW was Friday September 7, and the PS indicates that the member last worked September 7 as well, but that the member was on vacation and due to RTW Monday, September 17. The member did not RTW as scheduled. Review of the APS indicates that the member was in a boating accident on Thursday September 13 in the early morning. The date disabled would be:
A.
September 17
B.
September 8
C.
September 13
Correct Answer C. September 13
Explanation Regardless of the next scheduled workday, as the member was on vacation they were still “actively at work”. The first day the member was unable to work due to illness or injury whether scheduled or not was September 13.
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5.
The policy definition of disability is 24 months of total disability from the end of a 105 day QP with a RTW extending the QP. The date disabled is May 5, 2011 and the PS statement notes that the member RTW (M-F) to their own occupation from May 30 to June 9, 2011 inclusive. Based on this information, the BSD and COD dates would be:
A.
BSD is August 27, 2011 and the COD date is August 27, 2013
B.
BSD is August 18, 2011 and the COD date is August 18, 2013
C.
BSD is August 29, 2011 and the COD date is August 29, 2013
Correct Answer C. BSD is August 29, 2011 and the COD date is August 29, 2013
Explanation The 105 day QP is extended by the 11 calendar days covering the period that the member was not disabled from their own occupation during the QP. Therefore the BSD is August 29, 2011 (end of QP is August 17, 2011 + 11 days = August 28, 2011) and the COD date is August 29, 2013
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6.
On an ER certified group the PS statement indicates annual earnings of $45,000 yearly and the earnings noted on the Manuconnect benefit screen are $42,000 yearly. The LTD benefit is 60% x gross monthly earnings rounded to the next $1. The monthly benefit would be:
A.
$2,250 per month
B.
$2,100 per month
C.
$2,100 per month with a salary discrepancy investigation to be done
Correct Answer A. $2,250 per month
Explanation This is an ER certified (Self Administered) group. We do not maintain salary information on individual members for billing purposes. Therefore, there is no salary discrepancy to investigate and the benefit would be based on the ER’s reported earnings.
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7.
On the PS statement it is noted that the ER pays 100% of the LTD premiums, and according to Navigator policy inquiry the LTD benefit is non taxable. For claim set up purposes would you:
A.
Set up the claim with the gross benefit amount equal to the net benefit amount
B.
Set up the claim with the net benefit amount using the applicable tax table
C.
Set up the claim with the net benefit amount based on the applicable taxes and advise the Case Manager further investigation is required on the benefit taxability
Correct Answer C. Set up the claim with the net benefit amount based on the applicable taxes and advise the Case Manager further investigation is required on the benefit taxability
Explanation The claim system indicates that the benefit is non-taxable, and a T4 would not be generated. As such, it would be appropriate to set the claim up with the net benefit amount and update the File Notes requesting the Case Manager investigate and confirm benefits are non taxable.
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8.
Manuconnect indicates annual earnings of $53,000 on a Positive certified group with a committed date of January 1, 2012 and an applied date of November 1, 2011. Prior to this date the annual earnings on record were $49,000. The member became disabled on November 10, 2011. What amount of annual earnings should be used to calculate the LTD benefit amount? Should other action to be taken?
A.
$49,000 and advise PMA
B.
$53,000
C.
$49,000 and salary discrepancy investigation required
Correct Answer A. $49,000 and advise PMA
Explanation The annual earnings used to calculate the LTD benefit is $49,000 as the increase in earnings was processed and became effective after the date disabled and no salary discrepancy investigation is required. However, PMA should be advised as the retroactive increase was processed after the date disabled.
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9.
Review of the PS statement indicates that the member was paid salary continuance via the ER’s sick leave plan to September 14, 2011 inclusive. The date disabled is December 22, 2010 and the LTD QP is 180 calendar days or the expiry of sick leave, which ever is earlier. The BSD would be:
A.
June 20, 2011
B.
September 15, 2011
C.
December 23, 2010
Correct Answer A. June 20, 2011
Explanation The end of the calendar day waiting period (DOD Dec 22/10 + 180 days = June 19/11) is earlier than the date the sick leave benefits ceased. The period from June 20, 2011 to September 14, 2011 would be offset against the LTD benefit.
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10.
A salary of $65,000 is reported on the PS statement, and gipsy indicates annual earnings of $64,000 as of the date disabled. Monthly LTD benefits are based on 70% of gross pre disability earnings rounded up to the next $1. What earnings are to be used to calculate the monthly benefit? Is a salary discrepancy investigation required? Would it be
A.
$65,000 and no salary discrepancy investigation
B.
$64,000 and a salary discrepancy investigation
C.
$64,000 and no salary discrepancy investigation
Correct Answer C. $64,000 and no salary discrepancy investigation
Explanation Benefits are established based on either the lower of the amount reported on the claim form or the amount for which premiums have been paid. In this case the lower amount is $64,000. The difference in monthly benefit calculation is $58.00. ($65,000/12 x 70% = $3,792) – ($64,000/12 x 70% = $3,734) which is less than $100.month. Therefore no salary discrepancy investigation is required.
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11.
The member was in a motor vehicle accident on the way home from work on December 16, 2011. The next scheduled workday is December 19, 2011. There is a 6 month QP for LW. Based on this information the date disabled and LW Benefit effective date would be:
A.
December 16, 2011 and June 16, 2012
B.
December 17, 2011 and July 1, 2012
C.
December 19, 2011 and July 1, 2012
Correct Answer B. December 17, 2011 and July 1, 2012
Explanation The accident occurred after the completion of the workday, so the date disabled is December 17, 2011. LW is effective the first of the month coincident with or following the end of the 6 month QP, which is July 1, 2012.
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12.
On Navigator policy inquiry the LW maximum benefit date indicates to “age attained 65”, but the contract indicates to age 65. The member’s date of birth is April 21, 1958. What is the maximum LW date that should be set up? Is it:
A.
April 21, 2023
B.
April 20, 2023
C.
April 20, 2022
Correct Answer B. April 20, 2023
Explanation The contract provision specifically indicates “to age 65”, so the maximum date would be April 20, 2023. If it indicates “up to and including age 65”, then the date would be April 21, 2023.
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13.
The contract LW schedule indicates that there is a reduction in the Basic Life amount as follows: at age 60, with a further reduction every 5 years to age 70. The member’s date of birth is May 13, 1962. At what dates would the reductions take effect? Would they be:
A.
May 13, 2022, 2027, 2032
B.
May 12 2022, 2027, 2032
C.
May 13, 2027, 2032, 2037
Correct Answer A. May 13, 2022, 2027, 2032
Explanation The member turns 60 years of age on May 13, 2022 with another reduction at age 65- May 12, 2027 and a final reduction at age 70 – May 13, 2032.
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14.
Review of the PS statement indicates that the member's last shift worked was on July 5, 2011 with 5 hours worked on that day, no indication of usual work hours. The APS indicates that the symptoms began July 1, 2011 and the member was first treated on July 6, 2011. Based on this information the LW date of disability would be :
A.
July 6, 2011, and investigate/confirm confirm usual daily work hours
B.
July 6, 2011
C.
July 5, 2011
Correct Answer A. July 6, 2011, and investigate/confirm confirm usual daily work hours
Explanation If the member has worked more than 1/2 shift, then July 6, 2011 would be the date disabled. It would be prudent to contact the PS to confirm the usual daily work hours if it is not clear on the PS statement as some shifts could be up to 12 hours in length.
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15.
The policy benefit schedule indicates a 119 day QP for LTD benefits and a 180 day QP for LW with benefits waived from the first of the month coincident with or following the QP. Date of disability is September 1, 2011. The benefit effective dates for LTD and LW would be:
A.
Decenber 30, 2011 and February 28, 2012
B.
December 29, 2011 and March 1, 2012
C.
December 29, 2011 and April 1, 2012
Correct Answer B. December 29, 2011 and March 1, 2012
Explanation The date disabled is September 1, 2011 + 119 day LTD QP = December 28, 2011. LTD BSD is December 29, 2011. The date disabled September 1, 2011 + 180 day LW QP = February 27, 2012 – LW BSD is March 1, 2012 which is the first day of the month following the LW QP.
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16.
The annual earnings reported on the PS statement for an ER certified group are $72, 300. Manuconnect is showing earnings of $69,500 per year. The Life Amount is based on 2 x annual earnings rounded to the next $1,000. There is LW on the benefit schedule and basic Life is mandatory. The amount to be set up for life waiver is :
A.
$139,000
B.
$144,000
C.
$145,000
Correct Answer C. $145,000
Explanation As this is an ER certified group, the basic Life amount on waiver is based on the earnings as reported by the ER- 2 x $72, 300 = $ 145,000 (rounded up to the next $1,000).
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17.
The schedule of benefits indicates that there is waiver on basic life for a positive certified group with a reduction schedule noting that the benefit amount is reduced by 50% at age 65, and by a further 10% ever year thereafter. At age 70 the benefit is further reduced to $5000. The member’s date of birth is October 14, 1961 and Life amount is a flat $50,000. The dates and life amounts to be set up for LW according to the reductions are:
Explanation The 10% reduction schedule is calculated based on the reduced amount at age 65, which is $25,000 and not the initial face amount of $50,000.
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18.
Review of the Life coverage on Navigator policy inquiry does not indicate any waiver on Dependent Life coverage. However as per the policy schedule of benefits the coverage is mandatory for the member’s class and there is waiver. Under the circumstances the best course of action is:
A.
Set up the LW for the dependent coverage
B.
Do not set up the LW for the dependent coverage
C.
Do not set up the LW for the dependent coverage, update the ‘File Notes” and refer to Case Manager.
Correct Answer C. Do not set up the LW for the dependent coverage, update the ‘File Notes” and refer to Case Manager.
Explanation As there is a discrepancy between Navigator policy inquiry and the actual
Policy schedule of benefits, it should be noted on the claim and brought to the Case Manager’s attention for further investigation and follow up.
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19.
On a self administered group, the PS statement earnings are reported at $16.25 per hour and the member works 37.5 hours per week. Basic Life and AD & D both have waiver and the amounts for each are based on 2.5 x annual earnings rounded to the nearest $500. The amount to be set up for LW would be:
A.
$79,000
B.
$63,500
C.
$79,500
Correct Answer A. $79,000
Explanation The annual earnings are $31,687.50 ($16.25 x 37.5 x 52 weeks) x 2.5 = $ 79,218.75 rounded to nearest $500 = $79, 000.
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20.
Based on the date disabled, the PS statement indicates annual earnings of $57,500 and gipsy indicates annual earnings of $52,300. In the policy schedule of benefits for this positive certified group, it indicates that Basic Life is in the amount of $25,000 with Optional Life based on 3x annual earnings rounded to the nearest multiple of $500, and both have waiver. The LTD benefit is a flat amount of $2,500 per month. For the LW claims the amounts to be set up are:
A.
Basic Life - $25,000 / Optional Life - $172,500
B.
Basic Life - $25,000,/ Optional Life - $157,000
C.
Basic Life- $2,500/ Optional Life -$157,000
Correct Answer B. Basic Life - $25,000,/ Optional Life - $157,000
Explanation Amounts to be set up for Basic Life is the flat amount. The group is positive certified and the Optional Life amount is earnings based, the claim would be set up at the lower of either the amount reported on the claim form or the amount for which premiums have been paid according to gipsy, which in this case $157,000 ($52,300 x 3 rounded to the next multiple of $500).
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21.
Bonus Question: Based on the information outlined in questions # 20, would a salary discrepancy investigation be required?
#20- Based on the date disabled, the PS statement indicates annual earnings of $57,500 and gipsy indicates annual earnings of $52,300. In the policy schedule of benefits for this positive certified group, it indicates that Basic Life is in the amount of $25,000 with Optional Life based on 3x annual earnings rounded to the nearest multiple of $500, and both have waiver. The LTD benefit is a flat amount of $2,500 per month.
A.
Yes
B.
No
Correct Answer A. Yes
Explanation Yes a salary discrepancy investigation would be required. Although the LTD benefit and Basic Life amount would not be affected, the Optional Life amount is earnings based.