IRDA Test Preparation – IC 38 Health Mock Test 3 (50 Questions)

1. Rohit buys a policy and mentions “no prior illness.” Later, insurer finds he had hypertension diagnosed but untreated. Claim arises unrelated to hypertension. Insurer rejects claim citing non-disclosure.
What is the most appropriate interpretation?

2. An insured with two policies undergoes surgery costing ₹6 lakh. Policy A covers ₹5 lakh, Policy B ₹3 lakh. He claims full ₹6 lakh from Policy A only. What will happen?

3. Meena undergoes bariatric surgery due to obesity without any medical complications. She claims reimbursement. Which outcome is most appropriate?

4. An insured opts for a ₹50,000 deductible and ₹5 lakh cover. Hospital bill is ₹70,000. How much will insurer pay?

5. A patient undergoes cataract surgery in 10 hours of admission and discharge. Insurer denies claim citing 24-hour rule. What is correct position?

6. An insured intentionally exaggerates hospital bills using fake receipts. Which risk is demonstrated?

7. A family floater policy of ₹10 lakh covers 4 members. One member uses ₹9 lakh. Soon after, another member requires ₹3 lakh hospitalization. What happens?

8. A policyholder shifts insurer using portability but files claim immediately for a disease diagnosed earlier. What will insurer consider?

9. Hospital bill includes gloves, registration charges, and administrative fees. Insurer reduces claim.
Reason?

10. An insured delays claim intimation beyond allowed time but submits all documents later. Insurer rejects claim. Best justification?

11. A top-up policy has ₹3 lakh deductible. Base policy ₹3 lakh is exhausted. Additional ₹2 lakh expense occurs. What happens?

12. A policyholder undergoes treatment in a network hospital but chooses reimbursement instead of cashless. What is correct?

13. An insured conceals diabetes and develops kidney complication later. What is insurer likely to do?

14. An insured is hospitalized for observation without active treatment. Claim is denied. Why?

15. A person buys policy for parents aged 70+. Premium is very high. Main reason?

16. A claim arises due to accident leading to infection and death. Which cause is considered?

17. A policy once lapsed and renewed retains previous waiting period benefits.

18. A hospital inflates bill but insured is unaware. Insurer detects fraud. What happens?

19. An insured takes a hospital cash policy and incurs ₹1 lakh bill. Daily benefit is ₹3,000 for 5 days.
How much is paid?

20. A policyholder increases sum insured at renewal. Which condition applies?

21. An insured with copay 20% has ₹1 lakh claim. How much insurer pays?

22. A patient shifts to a more expensive room than eligibility. Claim is reduced. Why?

23. A policyholder dies after critical illness diagnosis. Which policy pays lump sum?

24. A claim is settled and insurer sues third party responsible for injury. Which principle?

25. A policyholder has a base policy of ₹4 lakh and a super top-up of ₹6 lakh with ₹4 lakh deductible. Two separate hospitalizations occur in a year: ₹3 lakh and ₹5 lakh. How much will super top-up pay?

26. An insured takes a policy and immediately undergoes treatment for hernia within 20 days. Policy has a 2-year waiting period for such conditions. What will happen?

27. A patient is admitted for fever, but during hospitalization, an unrelated surgery is performed. Claim is filed for both. Insurer will:

28. A policyholder buys insurance and intentionally understates age to reduce premium. Claim arises later. What is insurer’s most likely action?

29. An insured has a ₹2 lakh policy with ₹20,000 deductible and 10% copay. Hospital bill is ₹1 lakh.
How much insurer pays?

30. A policyholder undergoes organ transplant. Donor expenses are also included. Which statement is correct?

31. An insured chooses a room beyond eligibility limit, increasing overall bill including doctor fees. Insurer reduces entire bill proportionately. This practice is called:

32. A policyholder files multiple small claims just below deductible threshold frequently. Insurer observes pattern. What risk is being indicated?

33. An insured renews policy every year without break. In 5th year, he claims for a pre-existing disease. What is correct?

34. A patient is hospitalized abroad without prior approval. Policy covers worldwide emergency. What is likely settlement?

35. An insured dies due to complications after cosmetic surgery done for appearance. How will claim be treated?

36. A claim is filed after policy expiry but hospitalization started before expiry. What is correct?

37. An insured has ₹10 lakh cover but insurer pays only ₹7 lakh citing “reasonable and customary charges.” Why?

38. A policyholder upgrades from ₹3 lakh to ₹6 lakh cover. After 6 months, claim arises for ₹5 lakh disease. How much payable?

39. An insured undergoes treatment at a network hospital but opts for deluxe room instead of standard eligibility. Effect on claim?

40. A policyholder intentionally delays renewal to avoid premium increase but suffers illness during gap. What is outcome?

41. An insured is hospitalized twice for same illness within short period. Policy has no-claim bonus earlier. What happens to bonus?

42. A hospital splits one treatment into two admissions to maximize billing. Insurer detects this.
Likely action?

43. A policyholder claims for treatment taken at an unregistered clinic. What is likely outcome?

44. An insured with ₹5 lakh cover incurs ₹7 lakh expense and has no top-up. How much insurer pays?

45. A deductible and copayment can apply simultaneously in one claim.

46. A policyholder takes treatment in ICU without medical necessity. Charges are high. Insurer will:

47. An insured shifts insurer via portability but increases sum insured simultaneously. Which is correct?

48. After claim settlement, insurer recovers amount from negligent third party. What is this action called?

49. A claim is denied due to treatment not aligning with standard medical protocol. Which concept is applied?

50. Which is part of policy document?