To calculate the insured’s payment:
Deductible: The insured pays the first $1,000 of the $5,000 procedure cost.
Remaining cost: $5,000 - $1,000 = $4,000.
Coinsurance: The policy has 80/20 coinsurance, so the insurer pays 80% ($3,200) and the insured pays 20% ($800) of the $4,000.
Total paid by insured: $1,000 (deductible) + $800 (coinsurance) = $1,800.
Out-of-pocket maximum: The policy’s $3,000 out-of-pocket maximum caps the insured’s total payments. Since $1,800 is less than $3,000, the insured pays $1,800. However, the question asks for the total paid “towards the $5,000,” and the out-of-pocket maximum of $3,000 suggests a cap on total liability for covered expenses. In this context, the correct interpretation is that the insured’s payment is capped at the out-of-pocket maximum if applicable, but standard calculation yields $1,800, and the answer options suggest a possible intent for the maximum.
Upon review, the correct calculation yields $1,800 (Option C), but the out-of-pocket maximum of $3,000 (Option B) may be the intended answer if the question implies the maximum liability. Given the standard insurance calculation,Option C ($1,800)is mathematically correct, butOption B ($3,000)aligns with the out-of-pocket maximum as a potential cap. Since the calculation is clear, we selectC.
Corrected Answer: C
Explanation of Calculation:
Deductible: $1,000.
Coinsurance: 20% of $4,000 = $800.
Total: $1,000 + $800 = $1,800.
The out-of-pocket maximum ($3,000) is not reached, so the insured pays $1,800.
Option A: Incorrect. The insured does not pay the full $5,000 due to insurer contributions.
Option B: Incorrect. The $3,000 out-of-pocket maximum is not reached; the calculated payment is $1,800.
Option C: Correct. The insured pays $1,800 based on the deductible and coinsurance.
Option D: Incorrect. The $1,000 deductible alone does not account for coinsurance.
This question aligns with the Prometric content outline under “Provisions, Options, Exclusions, Riders, Clauses, and Rights,” which covers health insurance cost-sharing provisions.
[:, Prometric Oklahoma Life, Accident, and Health or Sickness Producer Exam Content Outline (Section: General Knowledge – Accident and Health Insurance)., Oklahoma Insurance Department, Title 36 O.S. § 6060.3 (health insurance policy provisions)., Standard insurance study guides (e.g., Kaplan, ExamFX) for Oklahoma producer licensing., , , ]
