The Claim Physician William Guillette M D Medical Director

							                                 The Claim Physician
                                            William Guillette, M.D.
                                               Medical Director
                                            Aetna Life & Casualty

 The importance of the role of physicians in the          management" as part of a Workers’ Compensa-
 development of the insurance industry, to us             tion claim management program. This type of pro-
 insiders, is a simple matter of record. Unfortunate-     gram includes:
 ly, most of our colleagues in active practice have       -- Medical Cost Control - pay only those
 little or no idea as to what goes on within our ranks          charges that are:
 and dismiss us as "insurance doctors" who sit                  ¯     within the fee schedule (when
around reviewing life insurance applications, us-                     applicable),
 ing a big underwriting manual, or harass them                  ¯ reasonable; i.e., that do not exceed
when they submit health claims, by requiring the                      the prevailing rate within the
completion of numerous forms. The "LMD’s" of                          community,
the world might have a different attitude towards               ¯ necessary for treatment of an injury
 us if they knew that the "big underwriting manual"                   or disease, causally related to
wouldn’t exist without physicians and the "claim                      employment,
forms" were developed by insurance industry                     ¯     monitor lengths of hospitalization
physicians working with the AMA to make their                         (and charges) and promote early
lives a little easier.                                                discharge.
 Naturally, the first involvement of physicians was       m Indemnity cost control -
in the life underwriting area but it wasn’t long
before they also became involved in claim issues.               ¯     monitor length of disability
This most probably first occurred with an individual            ¯     promote early return to work,
life policy and involved a medical opinion as to                ¯     determine availability of light work,
the cause of death, i.e., accidental versus natural             ¯     determine necessity of rehabilitation,
causes, or the presence of an undisclosed medical                     (physical and/or vocational).
condition(s) within the period of contestibility. As      -- Utilize a "hot line" number to the
the .scope of life insurance policies was broaden-              Medical Department, for the use of field
ed, with the addition of such features as waiver                claim personnel, for opinions as to:
of premium and accidental death benefits, the                  ¯      causal relationship, prognosis,
need for medical expertise in claim evaluations                      degree and length of disability, ap-
increased.                                                            propriateness of treatment, medical
The advent of Workers’ Compensation laws and                          charges, etc.,
the explosion in automobile ownership, in the early             ¯ advice as to the need for an in-
part of this century, lead to new types of insurance,                 dependent medical exam, what type
aimed at protecting the health as well as the life                    of specialist to use and what ques-
of an insured. From humble beginnings workers’                       tions to ask,
compensation laws now require employers to pro-                 ¯ direct communication between the
vide unlimited medical benefits to injured                           home office physician and the
employees. For many years insurance companies                        treating/consulting physician may be
have relied on medical expertise for opinions as                      indicated,
to: causal relationship appropriateness and                     ¯ early reporting of catastrophic
necessity of treatment, prognosis, degree of                         cases/, e.g., paraplegia, severe
disability (both partial and permanent), necessity                   burns, etc.) to enable the home of-
of future treatment, anticipated future costs and                    rice physicians to assist in the
need for consultation.                                               handling of these very expensive
With the increasing importance of this product line                  cases,
and the tremendous increase in the cost of pro-                ¯     more rapid identification of those
viding such benefits, some carriers have utilized                    cases where claimants should be
their physician’s expertise in the development and                   able to return to work and/or cases
implementation of the concept of "medical claim                      where early rehabilitation is indicated,



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The increase in the automobile personal liability                     development of average length of
insurance market has also been tremendous.                            disability guidelines,
When combined with the increased litigious nature                     development and implementation of
of the American society, it has resulted in a need                    rehabilitation programs for disabled
for physicians capable of reviewing files involv-                     claimants.
ing claimants suffering bodily injury for opinions
as to: causal necessity relationship, appro-               Another type of insurance was specifically
priateness and necessity of treatment, prognosis,          developed to attract the attention of a small, af-
degree of disability (both temporary and perma-            fluent section of society -- professional liability
nent) necessity of future treatment, anticipated           coverage for physicians. For over 50 years it was
future costs and the proper steps to be taken in           a consistent money maker for the underwriting
preparing a medical defense, if such is indicated.         companies. So few physicians were sued that a
                                                           clause was included in the contract, surrender-
Physicians have also been instrumental in the              ing the right of the insurance company to settle
development of No-Fault Medical Programs, in ap-           any claim without the insured’s written consent.
propriate states, to control medical expenses,             This was the only insurance contract in existence
assuring that all medical expenses applied to the          that gave the insured veto power over the in-
statutory threshold were medically necessary and           surance company and it was placed in the con-
appropriate. This necessitates obtaining the co-           tract as a "sales pitch" to attract business from
operation of local physicians who are willing to           physicians. This clause was to prove a major
promptly review cases involving questionable               stumbling block to reasonable settlements when
treatment and testify as to their findings.                the malpractice crisis developed in the 70’s. In-
                                                           surance physicians were needed to:
Meanwhile, during and immediately following
World War II, came the big explosion in group as                     review claims for opinions as to
well as individual health insurance plans. As these                  negligence and assist in defense
plans grew from simple hospital/surgical plans                       preparations by the identification of
with scheduled benefits, to complex, comprehen-                      appropriate consultants and suppor-
sive programs tied to the concept of reason-                         ting articles in the medical literature,
able~necessary treatment, the need for physicians                    participate in the development of
also grew. Insurance companies rely on physi-                        Risk Management Programs to
cian’s advice in establishing policy guidelines as                   assist health care professionals in
to what treatments are medically acceptable, as                      avoiding allegations of negligence.
well as in the following areas:
                                                           Finally, there has been an increased demand for
          interpreting medical reports to assist           physicians’ expertise in the product liability areas
          in determining the appropriateness               to review claims involving industrial exposures,
          /necessity of treatment and the                  such as asbestos, lead, mercury, and other poten-
          reasonableness of charges,                       tial toxic materials, as well as numerous drugs
          arranging independent consultations              (e.g., Chloromycetin, MER 29, birth control pills),
          and review of cases by peer review               vaccines (e.g., polio and flu) and medical devices
          organizations,                                   (e.g., the Dalkon Shield, etc.) and to develop in-
          liaison with healthcare providers and            formational material on products for use by field
          professional societies.                          personnel and defense attorneys.

With the growth of medical expense coverage has            A close look at "insurance doctors" reveals that
come disability insurance, both group and in-              they are deeply involved in many lines of in-
dividual, requiring physician’s expertise in:              surance. The responsibilities are varied, in-
                                                           teresting, and often times challenging. I am sure
          review of claims for opinions as to              that many of the more enlightened LMD’s respect,
          the necessity and reasonableness of              and even envy, our specialty today.
          disability,




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