Group LTD Claim Audit Findings | Canadian Institute of Actuaries 2009 Meeting

2009 General Meeting ●Assemblée générale 2009 Ottawa, Ontario ● Ottawa (Ontario) L’Institut canadien des actuaires Canadian Institute of Actuaries Session/séance : Group LTD Claim Audit Findings Speaker(s)/conférencier(s) : Kevin Braybrook

Background Initial Liability Decision Claim Management Change of Definition Staffing Presentation Outline

Common LTD Claim Audit Findings LTD Claim Audit Focus: Initial Liability Decision Claim Management Change of Definition Background

STD to LTD transition Eligibility Verification: Covered member; Actively at work; Prior Carrier; Proof of age; Pre-Existing Condition Investigation. Initial Liability Decision

Accurate Benefit Calculation: Verification of prior earnings; Reduction of benefits to match billing statements; All Source Maximum Calculations. Initial Liability Decision

Job Description and Physical Demands of the job Internet Searches Initial telephone interviews Initial Liability Decision

Review coverage information Disability definition verification Medical: Over “medicalizing”; Timing; Medical Consultant making claim decisions. Appropriate Offsets Acceptance Letters Initial Liability Decision

Claim adjudication vs. processing Caseload prioritization Claim Management

Claim management plans Short-term focused; Next steps; “Checklist” approach. Claim Management

Claim management tools: Independent Medical Examinations; Functional Claim Evaluations; Surveillance; Home Visits; Rehabilitation; Lump-sum settlements. Claim Management

Similar to initial liability decision Timing of investigation Medical documentation Document decision Change of Definition

Adjudicator empowerment Realistic and manageable caseloads Routine audits Staffing

QUESTIONS ?

Group LTD Claim Audit Findings | Canadian Institute of Actuaries 2009 Meeting