zen and the righteous claim outcome - · pdf filezen and the righteous claim outcome *** ......

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…

Name the famous Saint Paulite(s):

A. F. Scott Fitzgerald

(author)

B. Richard Dean Anderson

(MacGyver)

C. Charles M. Schultz

(cartoonist)

D. All of the above

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And now our first

“official” polling

question…

What is the most important component of the claim file?

A. Initial APS

B. Medical records

C. Expert materials

D. Decision letter

E. All of the above

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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?

✓ WHAT steps the

decision-maker took

✓ HOW the evidence

was evaluated

✓ WHO made

the decision

✓ WHEN the claimant

was involved

✓ WHY internal and

external sources

were relied upon

Why does the Claim File Matter?

It shows:

Your connection to the claimant


It shows:


That every claim has been reviewed on its own

merits and in light of similar claims


It shows:




Your employees are all focused on the same goal


It shows:





That you value the company’s reputation


It shows:

Your connection to the insured




That you value the company’s reputation

Why some claims cannot be paid

And now for another

polling question…

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

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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

The claim file = work put into the review

Tell the story of the claim

Decision letter incorporates the key parts of the

claim file

1 2 3

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 efforts to obtain information that could not be obtained

Ask 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.

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

B. Does not explain how insurer

interpreted the medical file reviews

C. Does not link evidence to policy

provisions

D. Both B & C

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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.

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

B. Does not explain insurers analysis of

the evidence

C. Does not define abbreviations

B. Does not state who treating physician is

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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.

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

B. Did not identify appeal committee members

C. No explanation of committee’s analysis of

evidence

D. A & C

E. B & C

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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.

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

C. Describes functional activities that are consistent with

the objective evidence and inconsistent with her

claimed reports

D. All of the above

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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.

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

B. Does not detail why evidence beneficiary

submitted is insufficient

C. Does not provide an analysis of the

insurer’s review of all the evidence

D. Contains “tone” in referring to beneficiaries

opinion as “purely speculative”

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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.

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.

B. Stated that the entire contents of the claim

file was considered

A. Although expressed sympathy, emphasized that claim

decision was based on policy provisions

C. Showed that the insurer performed a “full and fair”

review by talking with ME, claimant and having

independent physician review completed

D. Had independent reviewer consider tests

that were performed

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Questions/Discussion