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The Claim File
ZEN AND THE RIGHTEOUS CLAIM OUTCOME *** The Claim File Review & Decision Letter “Story” Kari Briscoe RGA Bill Hittler Nilan Johnson Lewis PA Objectives Increase knowledge of the importance of maintaining an organized and complete administrative claim file Raise awareness of the connection between claim department commitment to excellence and providing a fair written explanation of a claim denial to a claimant Using examples, identify essential components of decision letters that show the claimant has been treated fairly and that the decision is thoroughly explained Let’s test the polling system with a question about St. Paul, MN… 00:50 Name the famous Saint Paulite(s): A. F. Scott Fitzgerald (author) 0% B. Richard Dean Anderson (MacGyver) 0% C. Charles M. Schultz (cartoonist) D. All of the above 100% 0% And now our first “official” polling question… 00:53 What is the most important component of the claim file? A. Initial APS B. Medical records C. Expert materials 0% D. Decision letter 0% E. All of the above 0% 0% 100% Part I: The Claim File Adopting a holistic approach Reflecting employee integrity and commitment Complimenting an ongoing claim department education process Part II: The Adverse Decision Letter: Continuing the holistic approach Reviewing, explaining & weighing evidence Sharing letters (some reflecting that full and fair reviews have been completed and some that could be improved upon) I. CLAIM FILE Adopting a holistic approach The Claim File Doesn’t Put Itself Together What “Story” Does the Claim File Tell? ✓ WHATsteps the decision-maker took ✓ ✓ ✓ HOWthe evidence WHENthe claimant was involved WHOmade was evaluated the decision ✓ WHYinternal and external sources were relied upon Why does the Claim File Matter? It shows: Your connection to the claimant Why does the Claim File Matter? It shows: Your That connection to the claimant every claim has been reviewed on its own merits and in light of similar claims Why does the Claim File Matter? It shows: Your connection to the claimant That every claim has been reviewed on its own merits and in light of similar claims Your employees are all focused on the same goal Why does the Claim File Matter? It shows: Your connection to the claimant That every claim has been reviewed on its own merits and in light of similar claims Your employees are all focused on the same goal That you value the company’s reputation Why does the Claim File Matter? It shows: Your connection to the insured That every claim has been reviewed on its own merits and in light of similar claims Your employees are all focused on the same goal That you value the company’s reputation Why some claims cannot be paid And now for another polling question… 00:50 How is the Claim File Connected to ERISA Claim Procedures? A. ERISA requires that all verbal communication with the claimant be documented B. ERISA requires that a claims administrator adopt “reasonable” claim procedures C. ERISA requires that a CV/resume for anyone who reviews the file be placed in the claim file 33% 33% 33% How is the Claim File Connected to ERISA Claim Procedures? B. ERISA requires that a claims administrator adopt “reasonable” claim procedures ERISA “Administrative Claim File” “Relevant information” to be produced upon request Defined as info “Relied upon, submitted, considered or generated” And info that demonstrates compliance with administrative processes Non-ERISA Administrative Claim File Bias may be shown by failure to conduct a thorough investigation Duty of good faith and fair dealing requires that insurer will not deprive the insured of the benefits Translate Process into Priorities & Action Meaningful Interactive Subject to review + continual improvement * * * * * Judges and juries have the right to see what’s behind the claim file and decision letter Leadership by Example Golden Rules 1 2 3 The claim file = work put into the review Tell the story of the claim Decision letter incorporates the key parts of the claim file Employee Orientation Importance of preparing the file Need to organize Significance of documenting all activity Electronic data protocols Managers tasked with ensuring checks & balances Claim Department Education Scope + Content of Claim File Insurance policy or plan Notes Correspondence and emails Claimant’s statements & evidence supporting claim Medical records Research Government records Documents from Outside Sources Treating physician statements Expert reports Vocational assessments Labor market surveys Records provided to experts + curriculum vitae II. DECISION LETTERS Continuing the holistic approach used in preparing the claim file What “story” does the decision letter tell? Key Principles Minimum standard: “Full and fair review” “Meaningful dialogue” ERISA: court’s review limited to the “Four Corners” of the record Non-ERISA: insurer’s duty of ongoing investigation Universal Principles Letter must specify all of the reasons supporting the denial Cite to all of the policy provisions Fiduciary’s obligation to act in the interests of all plan participants What should the Letter reflect? Employees’ integrity and commitment All aspects of the claims review process All reasons the claim was denied All Elements United in a Common Goal Mindful Letter Writing Prepare an outline Organize the evidence supporting and not supporting approval Prioritize the evidence Own your position – you are the decision-maker Set the proper (objective) tone Minimize technical terms Quote entire policy language Follow claim procedures Review, Explain & Weigh Evidence Consider including proactive steps to reduce conflict of interest Confirm entire file has been reviewed Identify every non-expert and expert who has been involved in the decision Describe all proof supporting and not supporting the claim Weigh all evidence (explain why certain evidence is more important) Admit what is known to be true & untrue Describe Ask efforts to obtain information that could not be obtained someone to do a second read-through Useful Information False statements Claimant’s statements and conduct Physician records and observations Credibility assessments Independent data Outside reviewers & other experts Claim Denial Letter Scenarios 1 We have carefully reviewed your claim for disability benefits and have obtained two independent medical file reviews. Please see the attached reports. We have decided to deny your claim based on these reports. 00:43 1. We have carefully reviewed your claim for disability benefits and have obtained two independent medical file reviews. Please see the attached reports. We have decided to deny your claim based on these reports. A. Does not reflect that insurer reviewed all information in claim file 25% B. Does not explain how insurer interpreted the medical file reviews 25% C. Does not link evidence to policy provisions 25% D. Both B & C 25% 2 Our review of your claim included all of the information you submitted on appeal. Based upon the reviewing physician’s discussions with your primary treating physician and the results of the attached LMS and TSA, we regret to inform you that we have determined that you are not disabled under the plan terms. 00:46 2. Our review of your claim included all of the information you submitted on appeal. Based upon the reviewing physicians’ discussions with your primary treating physician and the results of the attached LMS and TSA, we regret to inform you that we have determined you are not disabled under the plan terms. A. Contains an emotional statement 25% B. Does not explain insurers analysis of the evidence 25% C. Does not define abbreviations 25% B. Does not state who treating physician is 25% 3 Your second appeal has been received and reviewed by our appeals committee. The committee has decided that for all of the reasons identified in its earlier letter to you, the decision to deny your claim for the life WOP benefit has been upheld on the basis that the objective proof of functional impairment from your daily living is demonstrably insufficient to satisfy your burden of proving entitlement to any benefits under the policy. 00:55 3. Your second appeal has been received and reviewed by our appeals committee. The committee has decided that for all of the reasons identified in its earlier letter to you, the decision to deny your claim for the life WOP benefit has been upheld on the basis that the objective proof of functional impairment from your daily living is demonstrably insufficient to satisfy your burden of proving entitlement to any benefits under the policy. A. Use of insurance jargon 20% B. Did not identify appeal committee members 20% C. No explanation of committee’s analysis of evidence 20% D. A & C 20% E. B & C 20% 4 Your claim for disability benefits is based in large part on your personal statements of ongoing, severe chronic pain and cognitive impairment. The company acknowledges that you have reported these conditions to your physicians on an ongoing basis. In the course of reviewing your claim, however, we note that the results of the independent neuropsychological testing show no cognitive impairment and your reported daily activities (working part-time, riding horses, performing volunteer tax preparation activities, and cross-fit competitions) show that you are functionally able to work in a light-duty occupation. 00:55 4. Your claim for disability benefits is based in large part on your personal statements of ongoing, severe chronic pain and cognitive impairment. The company acknowledges that you have reported these conditions to your physicians on an on going basis. In the course of reviewing your claim, however, we note that the results of the independent neuropsychological testing show no cognitive impairment and your reported daily activities (working part-time, riding horses, performing volunteer tax preparation activities, and cross-fit competitions) show that you are functionally able to work in a light-duty occupation. A. Acknowledges claimant’s reports to his/her physician B. Specifically refers to an objective test to assess the degree of cognitive impairment 25% 25% C. Describes functional activities that are consistent with the objective evidence and inconsistent with her claimed reports 25% D. All of the above 25% 5 We find that the proof you have submitted supporting your request for payment of life insurance benefits is insufficient under the terms of the policy. Specifically, the outside reviewing pathologist’s letter does not undermine the validity of the Medical Examiner’s report and your opinion on your husband’s state of mind is purely speculative. 00:55 5. We find that the proof you have submitted supporting your request for payment of life insurance benefits is insufficient under the terms of the policy. Specifically, the outside reviewing pathologist’s letter does not undermine the validity of the Medical Examiner’s report and your opinion on your husband’s state of mind is purely speculative. A. Does not identify experts 25% B. Does not detail why evidence beneficiary submitted is insufficient 25% C. Does not provide an analysis of the insurer’s review of all the evidence 25% D. Contains “tone” in referring to beneficiaries opinion as “purely speculative” 25% 6 The company expresses its sympathy for your loss. Our obligation under the policy, however, is to determine if the intoxication exclusion applies to your life insurance claim and if it does whether the exclusion bars you from receiving the benefits. In addition to reviewing all the documents contained in the claim file, we also interviewed the Medical Examiner, spoke with you over the phone, and obtained an independent physician review which included an assessment of your husband’s prior medical history and the results of all tests performed in connection with his accident. 00:55 6. The company expresses its sympathy for your loss. Our obligation under the policy, however, is to determine if the intoxication exclusion applies to your life insurance claim and, if it does, whether the exclusion bars you from receiving the benefits. In addition to reviewing all the documents contained in the claim fie, we also interviewed the Medical Examiner, spoke with you over the phone, and obtained an independent physician review which included a statement of your husband’s prior medical history and the results of all the tests that were performed in connection with his accident. A. Although expressed sympathy, emphasized that claim decision was based on policy provisions B. Stated that the entire contents of the claim 25% file was considered 25% C. Showed that the insurer performed a “full and fair” review by talking with ME, claimant and having independent physician review completed 25% D. Had independent reviewer consider tests 25% that were performed Questions/Discussion
