Associate, Life and Health Claims (ALHC)

Test wording, dates, and causal requirements. Apply the exact exclusion wording and its causal test to the dated condition and loss; a diagnosis by itself does not decide coverage.

Apply it: A prior diagnosis alone does not meet an exclusion; compare the clause’s causal test with the loss timeline.

Apply receipt conditions to verified chronology. Conditional-receipt coverage depends on the application, premium, insurability, and receipt terms that were satisfied on the loss date.

A diagnosis alone does not prove an exclusion applies; compare clause and timeline. A condition is excluded only if the contract’s trigger and causal connection are met during the relevant period.

Apply continuous and recurrent-disability provisions. Count qualifying disability days under the recurrence clause; separate episodes combine only when its gap rule permits.

Apply it: An application received March 4 and loss March 8 require checking conditional-receipt terms before using issue date.

Compare restrictions with material duties. Compare functional restrictions with the claimant’s material duties, not with diagnosis severity in isolation.

Apply own-occupation or any-occupation wording to the insured duties and documented functional limits. Own-occupation and any-occupation definitions ask different questions; apply the one in force for that benefit period.

Authenticate effective designation before payment. Pay only after authenticating the latest effective beneficiary designation and checking any required form or receipt conditions.

Apply it: With a 30-day wait, 24 disabled days plus 12 later days combine only if recurrence wording allows.

Record evidence, calculation, and decision rationale. Link medical and vocational evidence to the definition, dates, benefit calculation, and reason for the claim outcome.

Share personal and medical claim details only for authorized handling and review purposes. Restrict medical details to authorized claim handlers and preserve only information needed to support and review the decision.

Insurance and operations introductory courses. Introductory insurance and operations courses establish the base for later medical, legal, claim, and management study.

Apply it: A surgeon able to do desk work must be assessed against material surgical duties under the actual definition.

Medical, law, claim administration, and management C1–C4 connect medical knowledge, law, claim administration, and management to practical health-claim decisions.

Use the two introductory courses as the base, then connect C1–C4 to their distinct claims disciplines. Use course sequence to build contract foundations before assessing medical evidence, claim procedure, and management responsibility.

Confirm the insured event and contractual definition before calculating any benefit payable under the policy wording, including exclusions and waiting periods.

Apply it: Two beneficiary forms require authentication and effective-date checks before any payment is released.

Apply elimination and recurrence rules to dates. Map onset, continuous disability, recurrence, and waiting-period dates before counting eligible days.

Calculate benefit after applicable limits and offsets. Apply the policy maximum, offsets, and partial-disability terms to the gross benefit before stating payment.

Explain evidence needed and the contractual issue. Explain the exact contract issue and evidence still needed so the claimant can respond meaningfully.

Apply it: A new vocational report may justify reconsideration; explain the review route and preserve the response.

Reconsider when new evidence is material to the original definition, timeline, or functional assessment before issuing a final response explaining the outcome.

Use the appropriate review or complaint route. Use the appropriate internal review or complaint route and preserve the response and its basis.