A short presentation on disability claims and disability claim adjudication. While generic in focus, the content does make reference to several case management practices unique to CDCS.

1. Disability Claims 101
Presented by
Glenn Turner
Owner, Compass Disability Claim Solutions
www.compassdcs.com
Compass Disability Claim Solutions

2. Training Session Outline
• What is Disability Insurance?
• Nature of Disability Claims
• Benefit Plan Components
• Integrated Case Management
• The Claims Process
• Disability Claim Adjudication
• Claim Management
• Questions/Discussion

3. What is Disability Insurance?
Disability Insurance, often called DI or
disability income insurance, or income
protection, is a form of insurance that
insures the beneficiary's earned income
against the risk that a disability creates a
barrier for a worker to complete the core
functions of their work or at ‘change of
definition’, earned income in any occupation.

4. The Nature of Disability Claims
Occupational vs. Non-Occupational

5. Percentage
On Job Illness 0.4%
On Job Injury 3.5%
Off Job Illness 89.5%
Off Job Injury 6.6%
Disability Claims (Cross Spectrum)

6. What is Disability Insurance? (Cont’d)
Benefit vs. Entitlement
• ben·e·fit Pronunciation: be-nə-fit Function: noun Etymology: Middle English, from Anglo-French
benfet, from Latin bene factum, from neuter of bene factus, past participle of bene facere Date:
14th century 1archaic : 1: something that promotes well-being 2 a: financial help in time of sickness,
old age, or unemployment b: payment or service provided for under an annuity, pension plan, or
insurance policy. c: a service (as health insurance) or right (as to take vacation time) provided by
an employer in addition to wages or salary
• en·ti·tle·ment Pronunciation: -en-tī-təl-mənt Function: noun Date: 1942 1 a: the state or condition
of being entitled b: a right to benefits specified especially by law or contract 2: belief that one is
deserving of or entitled to certain privileges.
• Disability benefits are provided when a claim(ant) satisfies the requirements of the policy under
which the claim is submitted (i.e. the claim must meet the requirements of the policy).

7. Benefit Plan Components
• Waiting or “Elimination Period”
– Period between onset of disability and the point at which
benefits become payable.
• STD typically 7 days.
• LTD 120 to 180 days from disability onset.
• Definition of Disability:
– Unable to perform the substantial portion of:
• Own occupation
• Any occupation (Change of Definition – COD)

8. Benefit Plan Components (Cont’d)
• Partial Disability Benefits
– Reduced benefit to employees able to return to work in a limited
capacity (GRTW)
• Vocational/Occupational Rehabilitation Benefits
• Typically does not provide supplemental medical benefits.
• Integration of Disability Benefits
– Where benefits are receivable/payable from a third party or source,
payment from the company plan will be reduced accordingly
(precluding double indemnity).
– Subrogation vs. Offset:
• Subrogation: substitution of claimant’s ‘right to claim’ with that
of the company (typically applied to MVA but may involve
‘other’ accident – vicarious liability)
• Offset: CPP, Workers’ Compensation, Car Insurance.

9. The Claims Process
• The company plays a vital role in the claims administration and
adjudication process through the timely, effective, and accurate
collection and submission of claim related documents:
– Claimant Statement
– Employer Statement
– Third Part Administrator (TPA) Form
– Attending Physician Statement
– Other special documents as required:
• Subrogation Agreement
• Claimant Statement (MVA)
• Claimant Statement (Accident/Incident)
• Claim application packages should not be forwarded to the
insurer until they are complete.

10. Claim Adjudication
The insurer is responsible for the quality control
of all claim applications, the medical adjudication
of claims, preliminary adjudication by policy, and
processing of claims.

11. Claim Adjudication

12. Claim Adjudication
• Disability claim
adjudication is as much
an art as it is a science.
• Adjudication is guided
by the principle of
“Good Faith”.

13. Claim Adjudication
• Adjudicative Process:
– Status of Policy (Policy Number, Class, Effective Date, Premiums, etc.)
– Endorsements (‘Top Up”)
– Misrepresentation/non-disclosure
– Nature of Claim
• Physical
• Psychiatric
• Soft
– Pre-existing condition(s)
– Recurrence
– Occupational duties
– Does it make sense? (accident/injury)
– Timely and appropriate medical treatment?
– Secondary gain factors?
– Double Indemnity (Alternate insurance, WCB, CPP, Medical EI, etc.)

14. Claim Adjudication (Cont’d)
• Apart from initial evaluation, claims must be scrutinized on an ongoing
basis.
• Tools:
– Supplemental Medical
– Independent Medical Examination
– Functional Capacity Evaluation
– Claimant questionnaire/statements
– Telephone survey/Field visit
– Surveillance
• Timelines (Insurer decisions):
– STD applications: five business days from receipt
– LTD applications: ten business days from receipt
• Accepted/Pending/Suspended/Denied (Appeals, Claim Review Committee)

15. Claim Management
• The designated Early Intervention/Return to Work Coordinator is
expected to maintain contact with approved claimant’s in a
supportive role and to provide periodic updates to the case manager
with respect to their status and return to work potential for the
duration of the claim.
• Facilitate early return to work/return to work planning.
• The designated case manager is tasked with the timely, effective and
efficient management (including administrative and medical
aspects) of assigned claims.
– Ongoing liaison with designated case manager
– Supplemental medical requests
– Medical Coordination provisions
– Rehabilitation Coordination provisions

16. Appeals
• A claimant has the right to appeal a decision of
all or part of the benefits denied them.
• Appeals must be submitted in writing within
one year.
• Must include detailed explanation as to
disagreement with decision supported by
objective facts and evidence.
• Claimant responsible for all costs.
• Levels of Appeal:
– 1st Level Appeal
– 2nd Level
– 3rd Level Appeal

17. Disability Claim Process Summary
RTW
Early Intervention
Collate application
Submit complete application package to carrier
Adjudication
Issue decision
Case management (directed towards RTW)
Return to work planning
Overseen by case manager with input from
appropriate subject matter experts
Successful RTW/COD

18. Questions & Discussion