Missouri Claims Review Specialist Exam
Practice Questions And Correct Answers
(Verified Answers) Plus Rationale 2026
Q&A| Instant Download Pdf
1. A claims review specialist is evaluating a property insurance claim
where the insured reports water damage allegedly caused by a burst
pipe. The documentation includes photographs, contractor estimates,
and prior maintenance records. Which of the following steps is MOST
appropriate for ensuring claim validity before approval?
A. Immediately approve the claim if photographs appear consistent with
water damage
B. Compare maintenance records with the date of loss and verify causation
through independent inspection
C. Deny the claim because water damage is generally excluded under all
policies
D. Approve the claim but reduce payment by 50% as standard procedure
,Answer: B
The most appropriate action is to verify causation by comparing
maintenance records with the date of loss and conducting an independent
inspection, ensuring the damage is covered and not due to neglect or pre-
existing conditions.
2. In claims processing, what is the PRIMARY purpose of subrogation
after an insurer pays a claim?
A. To increase premiums for high-risk policyholders
B. To recover paid claim funds from a responsible third party
C. To cancel policies of negligent insured individuals
D. To reduce documentation requirements for future claims
Answer: B
Subrogation allows the insurer to recover costs from a third party legally
responsible for the loss, preventing unjust enrichment of the insured and
controlling insurance costs.
3. A claimant submits a suspicious injury claim with inconsistent medical
reports from different providers. What is the BEST next step for a
claims review specialist?
A. Immediately deny the claim without explanation
B. Refer the claim to a fraud investigation unit for further review
,C. Approve based on the most recent medical report
D. Request premium payment confirmation before proceeding
Answer: B
Inconsistencies in medical documentation may indicate potential fraud, so
referral to a specialized fraud investigation unit ensures proper evaluation
and compliance with investigative protocols.
4. Which of the following best defines “moral hazard” in insurance
claims?
A. A natural disaster increasing claim volume
B. A policyholder increasing risk behavior after obtaining coverage
C. A government regulation increasing claim approval time
D. A reduction in premiums due to safe driving records
Answer: B
Moral hazard occurs when insured individuals behave more recklessly
because they are protected financially by insurance coverage.
5. A claims specialist notices that a fire claim includes items purchased
after the reported date of loss. What is the MOST likely concern?
A. Inflation adjustment requirement
B. Documentation error in depreciation
, C. Potential fraud or misrepresentation
D. Policy premium misclassification
Answer: C
Items purchased after the date of loss suggest falsification of claim
contents, indicating potential fraud or misrepresentation requiring further
investigation.
6. Which principle governs the requirement that insurance claims must
be handled fairly and promptly?
A. Utmost good faith
B. Comparative negligence
C. Indemnity avoidance
D. Salvage limitation
Answer: A
Utmost good faith requires both insurer and insured to act honestly and
fairly, ensuring timely and accurate claims handling.
7. A claims reviewer is assessing whether damages fall under policy
coverage. What document is MOST critical in this evaluation?
A. Employee attendance record
B. Insurance policy contract
Practice Questions And Correct Answers
(Verified Answers) Plus Rationale 2026
Q&A| Instant Download Pdf
1. A claims review specialist is evaluating a property insurance claim
where the insured reports water damage allegedly caused by a burst
pipe. The documentation includes photographs, contractor estimates,
and prior maintenance records. Which of the following steps is MOST
appropriate for ensuring claim validity before approval?
A. Immediately approve the claim if photographs appear consistent with
water damage
B. Compare maintenance records with the date of loss and verify causation
through independent inspection
C. Deny the claim because water damage is generally excluded under all
policies
D. Approve the claim but reduce payment by 50% as standard procedure
,Answer: B
The most appropriate action is to verify causation by comparing
maintenance records with the date of loss and conducting an independent
inspection, ensuring the damage is covered and not due to neglect or pre-
existing conditions.
2. In claims processing, what is the PRIMARY purpose of subrogation
after an insurer pays a claim?
A. To increase premiums for high-risk policyholders
B. To recover paid claim funds from a responsible third party
C. To cancel policies of negligent insured individuals
D. To reduce documentation requirements for future claims
Answer: B
Subrogation allows the insurer to recover costs from a third party legally
responsible for the loss, preventing unjust enrichment of the insured and
controlling insurance costs.
3. A claimant submits a suspicious injury claim with inconsistent medical
reports from different providers. What is the BEST next step for a
claims review specialist?
A. Immediately deny the claim without explanation
B. Refer the claim to a fraud investigation unit for further review
,C. Approve based on the most recent medical report
D. Request premium payment confirmation before proceeding
Answer: B
Inconsistencies in medical documentation may indicate potential fraud, so
referral to a specialized fraud investigation unit ensures proper evaluation
and compliance with investigative protocols.
4. Which of the following best defines “moral hazard” in insurance
claims?
A. A natural disaster increasing claim volume
B. A policyholder increasing risk behavior after obtaining coverage
C. A government regulation increasing claim approval time
D. A reduction in premiums due to safe driving records
Answer: B
Moral hazard occurs when insured individuals behave more recklessly
because they are protected financially by insurance coverage.
5. A claims specialist notices that a fire claim includes items purchased
after the reported date of loss. What is the MOST likely concern?
A. Inflation adjustment requirement
B. Documentation error in depreciation
, C. Potential fraud or misrepresentation
D. Policy premium misclassification
Answer: C
Items purchased after the date of loss suggest falsification of claim
contents, indicating potential fraud or misrepresentation requiring further
investigation.
6. Which principle governs the requirement that insurance claims must
be handled fairly and promptly?
A. Utmost good faith
B. Comparative negligence
C. Indemnity avoidance
D. Salvage limitation
Answer: A
Utmost good faith requires both insurer and insured to act honestly and
fairly, ensuring timely and accurate claims handling.
7. A claims reviewer is assessing whether damages fall under policy
coverage. What document is MOST critical in this evaluation?
A. Employee attendance record
B. Insurance policy contract
