Group STD & LTD

Claim Philosophy

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Each claim presents a unique set of facts and circumstances which merit thorough investigation and objective evaluation. Proactive and expert management is necessary to ensure that each claim is accurately and efficiently adjudicated.

Each claimant deserves to be treated with dignity and respect, and is entitled to a fair and timely benefit determination.

Claim Management Approach

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    1. Leverage well trained, experienced and highly skilled claim professionals who can think critically and work proactively.
    2. Utilize an activity based claim objectification approach stressing early and direct involvement by qualified professionals.
    3. Integrate specialized clinical and disability claim management resources to ensure comprehensive benefit eligibility assessment.
    4. Enable claim experts through the deployment of proprietary technology that enhances communication and operating efficiency.

Short-Term Disability Triage Process

  • Claim examiners dedicated to employer groups
  • System automation capability for caseload balancing with potential for diagnosis driven assignment
  • Claim management triage to match complexity of the claim with appropriate resource

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Effective STD & LTD Integration

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Enhanced by Technology

  • Short-Term Disability and Long-Term Disability claims reside in one system
  • Diary for automated event triggering
  • Data integrity maintained as Short-Term Disability flows to Long-Term Disability
  • Reporting allows for trend analysis for employer, insurer and management

Long-Term Disability Triage Process

  • Claim examiners dedicated to employer groups
  • System automation capability for caseload balancing with potential for diagnosis driven assignment
  • Claim management triage to match complexity of the claim with appropriate resource

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Early Intervention Through Clinical Case Management

DMS works with the claimant, the physician, and the employer to understand the nature of the condition(s) to facilitate return to work when possible.

Direct Contact

  • Claimant interviews
  • Discussion with employer for accommodations
  • Attending Physician calls

Education

  • Employee
  • Physician
  • Claim Examiner

Clarification of Restriction & Limitations

  • Independent Medical Exams (IME)
  • Independent Peer Reviews
  • Functional Capacity Evaluations (FCE)
  • Collaboration with the claim examiner in development of the claim action plan in accordance with policy provision
  • Introduction to vocational rehabilitation staff to facilitate/coordinate the Return to Work effort

Return to Work

Vocational Resource Utilization

Establishing a Return to Work hierarchy through contact with the claimant, the physician and employer to facilitate a successful return to work in collaboration with the claim examiner and in accordance with policy provisions.

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Managing Complex Claims

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Early intervention helps identify problematic claims which may require additional resources to fully assess the medical, occupational and situational factors present. Timely and appropriate resource utilization leads to good decision making and effective duration management.

Effective Duration Management

Managing claims beyond the initial decision

  • Establishing an action plan that is reasonable and tailored to the specific uniqueness of each claim
  • Awareness of prognosis and applying the appropriate level of resource in assessing ongoing benefit eligibility
    • Is condition expected to change over the next 6-12 months? 12-24 months?
    • Change in definition evaluation
    • Opportunity to pursue Rehabilitation and Retraining
    • If condition is not expected to change, periodic physician statements and
      periodic updated medical records may be appropriate along with application for Social Security benefits

Social Security Advocacy

Keys to success:

  • Early identification and early intervention
  • Selection of best-in-class Social Security vendors

Social Security process:

  • DMS identifies SSDI candidate
  • Vendor reviews and contacts claimant
  • Vendor represents claimant throughout process and handles all appeals
  • Vendor receives early notification of SSDI award from SSA
  • Overpayment calculated by DMS & detailed correspondence sent to claimant
  • SSA issues retro SSDI benefits
  • Vendor electronically sweeps overpayment from claimants bank account
  • Overpayment forwarded to DMS

Additional Offset Management

check-boxesReview for additional sources of income:

  • Workers’ Compensation
  • Retirement/Pension
  • Return to Work Earnings
  • Other
    • Diary system to monitor and track potential other income sources for coordination with LTD benefits at appropriate intervals
    • Comprehensive overpayment tracking for tax reporting and collection
    • Dedicated Financial Claim Consultant(s) to assist in claim benefit recalculations as other income is awarded

Comprehensive Reporting & Superior Experience Monitoring/Trend Analysis

Claim activity monitored through analysis of various reports:

  • Actual versus Expected Outcomes
    • Based on assumptions
  •  Delineation of claim outcomes based on closure reasons
    • Return to Work Own Occupation
    • Return to Work Any Occupation
    • Not Disabled Own Occupation
    • Not Disabled Any Occupation
    • Death
    • Settlement
    • Vocational Settlement
    • Maximum Benefit Duration
    • Limitation (i.e. Mental Nervous Limit, Subjective Claim Limit)
  • Measure of financial offset recalculation
    • Overpayment reports
    • Overpayment Recoveries via benefits or external resources
  • Claim Management Activity
    • New Notices
    • Claims under review
    • Claims in maintenance status
  • Trends
    • Claims by region
    • Claims by diagnosis
    • Claims by occupation
    • Claims by employer
    • Claims by doctor
    • Claims by disability type