Complex Claims Investigations (2012 ICA)
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This document outlines an agenda and case studies for a presentation on complex claims investigations. The presentation covers contestable investigations, suicide investigations, accidental death policies, and critical illness riders. Case studies are provided for each topic, describing fact scenarios and policy provisions. The purpose is to identify relevant questions to ask given the specific facts and contract language. The goal is to have a fair and consistent process for rendering reasonable claims decisions. Attendees are encouraged to ask questions.
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Complex Claims Investigations (2012 ICA)
- 1. Complex Claims Investigations Michael Hoetzel, ALHC Life Claims Manager Farmers New World Life Insurance Company Robert R. Pohls Pohls & Associates Los Angeles, California Craig Williamson, CFE, ALHC Special Investigations Unit Manager Farmers New World Life Insurance Company International Claim Association – 2012 – Orlando, FL – October 2, 2012
- 2. Complex Claims Investigations International Claim Association – 2012 – Orlando, FL – October 2, 2012 1. Introductions 2. Case Studies a. Contestable Investigations b. Suicide Investigations c. Accidental Death Policies d. Critical Illness Riders 3. Questions FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 2
- 3. Complex Claims Investigations International Claim Association – 2012 – Orlando, FL – October 2, 2012 Approach- Fact gathering from the claim perspective Justification- Reach a decision that is supported by contract language and facts specific to a claim Decision- Communicate decision Defense- Litigation Management with assistance from in-house and/or outside counsel Resolution- Pay benefit based on new facts, compromise resolution or verdict FACT SCENARIOS QUESTIONSAGENDA VIEWPOINT REVIEW 3
- 4. International Claim Association – 2012 – Orlando, FL – October 2, 2012 Purpose To identify what questions to ask that are relevant to the facts specific to a claim and the underlying contract. Goals Provide an environment that enables a fair and consistent process that supports a good faith effort in rendering a reasonable claims decision. We are here to help and to provide our varied experiences and expertise within the following scenarios….So here we go! FACT SCENARIOS QUESTIONSAGENDA VIEWPOINT REVIEW 4 Complex Claims Investigations
- 5. International Claim Association – 2012 – Orlando, FL – October 2, 2012 CONTESTABLE INVESTIGATION Fact Scenario # 1: 31 y.o. female applies for $50K term life policy 5’1” and 120 pounds Non-smoker “Clean” application Conditional receipt given in exchange for first premium Insured dies less than 12 hours after policy issued Cause of death: congestive heart failure Coroner’s report: 5’4” and 308 pounds FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 5 Complex Claims Investigations
- 6. International Claim Association – 2012 – Orlando, FL – October 2, 2012 CONTESTABLE INVESTIGATION Fact Scenario #2: 46 y.o. male applies for $1M term life policy Denies use of controlled substances Alcohol use: “Couple of beers socially” Insured is shot and killed during contestability period -Killer was trying to get insured to go to rehab Problem: paramed exam showed elevated liver enzymes FACT SCENARIOS QUESTIONSAGENDA VIEWPOINT REVIEW 6 Complex Claims Investigations
- 7. International Claim Association – 2012 – Orlando, FL – October 2, 2012 SUICIDE INVESTIGATION Fact Scenario #1 28 y.o. female applies for $250K term life policy (5 y.o. son is beneficiary) Dies as result of self-inflicted gunshot wound to chest Alone in boyfriend’s bed Seen with gun earlier in evening (raccoons) Three prior suicide attempts Reportedly jumped in front of a bus Reportedly tried to overdose on drugs Autopsy report: hesitation marks Witness statements: happy, interacting with family and friends, giving gifts FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 7 Complex Claims Investigations
- 8. International Claim Association – 2012 – Orlando, FL – October 2, 2012 SUICIDE INVESTIGATION Fact Scenario # 2 58 y.o. male applies for $125K term life policy Dies less than 2 years later after taking 24 Tramadol pills Pills had been prescribed for his girlfriend Autopsy report: some alcohol in his system at time of death Limited death benefit for suicide during first two years Beneficiary: Insured did not mean to take his own life, Just wanted attention and did not understand proper dose. FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 8 Complex Claims Investigations
- 9. International Claim Association – 2012 – Orlando, FL – October 2, 2012 SUICIDE INVESTIGATION Fact Scenario # 3 58 y.o. motivational speaker with severe financial problems Applies for approximately $18M in life insurance with different companies Reportedly pays a man on the street to kill him Asked him to make it “look like a robbery” so his family could get “what they deserve” Killer is convicted of second-degree murder FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 9 Complex Claims Investigations
- 10. International Claim Association – 2012 – Orlando, FL – October 2, 2012 ACCIDENTAL DEATH INVESTIGATION Fact Scenario # 1 $50K AD&D policy covers “[d]eath resulting directly from bodily injury effected solely through external, violent and accidental means.” Accident: Not defined. Insured drove car off an embankment and was trapped in 100 degree heat for 8 hours Died three days after rescue (chronic obstructive pulmonary disease, auricular fibrillation, cerebrovascular event and congestive heart failure) Doctor’s note: being seated for hours after the accident increased risk of thrombosis FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 10 Complex Claims Investigations
- 11. International Claim Association – 2012 – Orlando, FL – October 2, 2012 ACCIDENTAL DEATH INVESTIGATION Fact Scenario # 2 $250,000 Accidental Death policy issued to 29 y.o. male Insured dies in motor vehicle accident with BAC: 0.15 (legal limit 0.08) Exclusion: losses caused by “intoxication” as defined by the State where the death occurred. Cut off by other car and drove onto dirt median Overcorrected and ran off road Thrown from car, flipped 3x, landed on top of him Witnesses statement: Insured was in a speed contest FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 11 Complex Claims Investigations
- 12. International Claim Association – 2012 – Orlando, FL – October 2, 2012 CRITICAL ILLNESS INVESTIGATION Fact Scenario # 1 35 y.o. special education teacher $250K whole life policy which includes a Critical Illness Rider Within 1 year of the policy issuance, insured files a CI claim as a result of being diagnosed with breast cancer. Maximum CI benefit available is 150K Based on the documents provided by her physician, the cancer was diagnosed 1 year prior to the policy’s Effective Date. Policy Provision Preexisting Conditions: A condition for which symptoms existed within two years prior to the later of the Rider Effective Date or the effective date of any rider reinstatement. If the Insured is Diagnosed with a Covered Condition that we determine to be a Preexisting Condition, no Benefit Amount is payable for the Covered Condition. FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 12 Complex Claims Investigations
- 13. International Claim Association – 2012 – Orlando, FL – October 2, 2012 CRITICAL ILLNESS INVESTIGATION Fact Scenario # 2 55 y.o. widowed architect with four children two of which are adopted $1M Universal Whole Life which includes a Critical Illness Rider Maximum CI benefit available is 250K Insured has a heart attack 6 months after the policy’s Effective Date. The insured subsequently submits a claim for CI benefits. Policy Provisions 30 day Waiting Period after Effective Date wherein first symptoms occurred that lead to Diagnosis. At Claim time it was discovered Heart Attack was diagnosed 40 days after Effective Date of policy, however condition started 10 days prior to diagnosis. FACT SCENARIOS QUESTIONSAGENDA Viewpoint Review 13 Complex Claims Investigations
- 14. Complex Claims Investigations International Claim Association – 2012 – Orlando, FL – October 2, 2012 QUESTIONS? CLAIM STRATEGIES QUESTIONSAGENDA RESCISSION CHECKLIST 14