Disability claims internal reviews are not done in random; there is a hierarchy to the review that most claimants either don’t know about, or perhaps do not understand.
When claims are submitted for payment, insurers will begin with an “initial review” of the claim. The results of the review depend on the expertise and experience of claims handlers. Today, and given the quality of employees associated with claims, I never trust the initial review is ever done. Here are the aspects of a new claim review that are usually done first before anything else. If the claim does “not meet the conditions of the first review, the claim is denied, and no further reviews are done.
- Check “Class” of employee to see if claimant is in a covered Class of employees.
- Review “Effective Date of Coverage’, Plan policy provisions regarding pre-existing conditions, to determine if a pre-existing condition investigation should be made.
- Verify employer, occupation with a Job Description, and obtain previous years W-2, or verify according to the Plan.
- What is the benefit percentage, minimum payment amount qualification.
- What is the Elimination Period? Did the claimant meet the EP, or, did the claimant work during the EP? Calculate days that counted toward EP if claimant worked part-time during the EP.
- What is the claimant’s definition of Monthly Earnings from Plan? Calculate the claimants pre-disability earnings and payable benefit. Some insurers forward claim to financial areas to calculate pre-disability earnings particularly for IDI claims.
- Verify occupation and wage amounts in keeping with how the Plan describes.
- If the Plan is an Employer’s Group Plan then document, and make note it has a federal ERISA jurisdiction.
In fact, if you look closely that this list and compare it to the first several pages of your group Plan, it contains all of the above information. The first several pages of any Group Plan is referred to as the “Summary Plan Description” or SPD.<.p>
I’ve actually written a 100 page book called “Group LTD 101”, and I’m happy to provide it to anyone who makes at least a $20 Donation from my website. http://www.disabilityclaimssolutions.com. This book is in a Workbook format and goes through a typical LTD Plan in detail. If you’re looking to learn about Group Employer Plans, this Group LTD 101 is an excellent resource. I’ve included other data at the back as well. Clients of DCS can just send an email and I’ll send it to you without cost.
Group LTD 101. $20 Donation from website:
http://www.disabilityclaimssolutions.com
Please contact me if you have any questions.
