The claims process for private disability changed. It happened so silently, and covertly, that claimants and insureds failed to notice subtle changes in communications and how insurers have tightened the reigns to make denying claims easier, more efficient, more credible and more difficult to reverse.
While insureds continue to presume medical information is reviewed by internal insurance physicians, and claims handlers continue to make claim decisions, etc., the new normal is clearly not that. In fact, very little of the claims process is completed by employees working in an insurance facility or campus.
In the last ten years most insurance companies downsized, and have significantly reduced employees to unworkable levels. Medical reviews and nearly every internal departmental function within the claims process is outsourced to third-party chasers and reviewers as cost-effective measures. Quality within the claims process went out the door, replaced by objective, no-interest facilities who charge piece work fixed fees to support insurance business agenda.
“So, what’s changed exactly, and what does that mean for me and my claim?”, you’re asking. Well, let’s take a look.
Untimely
Any time a claim, or portion of it, is transferred to another department, or outside of the company for review, insureds are facing least three weeks of “review time” before the claim can move on in the review process. Claim decisions ARE NOT made in a timely fashion now and decisions seem to drag on and on. I hear a great deal from insureds telling me how much they need benefit money, but the truth is insurance companies work on their own timelines not ours. It is extremely unrealistic for insureds to expect payment of benefits right away. It’s not going to happen.
Most companies are scrambling to handle huge back logs of claims making timely decisions a certain impossibility.
Medical reviews outside of insurance company base.
Medical reviews sent to treating physicians for comment will be from outside third-party facilities, not recognizable by insureds. Apparently, GENEX is now used by insurers to complete medical reviews in addition to any occupation investigations, and vocational reviews. Insurers are using top-credentialed physicians to discredit treating physician medical reports and frankly, these reports appear credible next to treating physician reports that lack detail and specificity.
The new normal for medical review is out-sourced, third-party reviews by old-time insurance claim killers paid for by the insurance industry. Insureds who are accustomed to sending in update forms with minimal marks on the APS statement will find their claims left in the dust of expert medical review.
Claims handlers are not aware of the history of your claim.
Today, the new normal is for claims reps, who are little more than administrative assistants by the way, is to read the top 10 electronic pages of a file and that’s it. Each specialist manages blocks of claims of of up 200 claims. It is impossible to read several hundred pages of any one claim and therefore claims reps operate blind-sided to anything that happened on a claim six months ago. This is why insureds are always asking me, “Didn’t they know….? Why are they asking me that again?” Many requests are repeated over and over again because claims reps aren’t reading the files.
Claims reps are “robots” and are located sporadically in different locations.
In order to save money, insurers now employ robot claims specialists located all over the country to include India, the Philippines, and Thailand. US insureds never really know who they are talking to when customer service is contacted. Phone calls are telephonically transferred outside of the company to….where? We never know.
The educational quality and intelligence of claims handlers hired is directly related to the downsized salaries they are now paid. In addition, internal training protocols have been “dumbed down” to take claims reps out of play for litigation. Claims handlers are NOT contract specialists and communications are derived from pull-down templates of citations they don’t understand and can’t explain.
Claims “specialists” aren’t specialists at all, and are supervised by managers who at times know less than they do. Insureds should never depend on claims handlers to answer questions or give significant advice or direction.
Although I could write a great deal more here, I think you get the picture. The claims process changed while claimants/insureds and their physicians slept peacefully thinking everything remained the same.
While DCS, Inc. is changing many of its strategies to meet the “new normal”, those who are sending in their own paperwork thinking they are dealing with the status quo are likely punting in the dark.
Everything about the claims process changed. While in the past private disability might have given the illusion of internal concern and fairness, there is no longer any illusion. In fact, it’s all quite openly admitted now.
Claims decisions are based on reviews performed by sterile, out-sourced resources for minimal cost, backed by management to keep the widgets flowing down the assembly line in a cost-effective way. If you ever had a thought that YOUR claim was managed fairly, you need to adjust your thinking to the “new normal” and change the way you do things.
For insureds, it’s a whole new ball game with bases loaded for the opposing team.
If you are having difficulty managing the automated claims process, or any other claims issue, please contact me for a free consultation about coming on board as a DCS, Inc. client.
DCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation and I’m happy to discuss how you can become a DCS client.
If you need assistance with filling out your update forms or questionnaires, please feel free to give me a call at (207) 793-4593. The claims process is not what you may think it is if you aren’t familiar with insurance company changes.
If you are interested in becoming a DCS client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com
