Canadian Institute of Actuaries L�Institut canadien des actuaires

							       Canadian                  L’Institut
        Institute                canadien
               of                des
       Actuaries                 actuaires
  2009 General Meeting ● Assemblée générale 2009
              Ottawa, Ontario ● Ottawa (Ontario)

Session/séance : Group LTD Claim Audit Findings
Speaker(s)/conférencier(s) : Kevin Braybrook
      Presentation Outline
•   Background
•   Initial Liability Decision
•   Claim Management
•   Change of Definition
•   Staffing
              Background
• Common LTD Claim Audit Findings

• LTD Claim Audit Focus:
   – Initial Liability Decision
   – Claim Management
   – Change of Definition
  Initial Liability Decision
• 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
    Claim Management

• 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.
    Change of Definition
• Similar to initial liability decision

• Timing of investigation

• Medical documentation

• Document decision
               Staffing
• Adjudicator empowerment

• Realistic and manageable caseloads

• Routine audits
QUESTIONS ?