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June is a time when the temperatures rise, days grow longer and according to custom, it becomes acceptable to wear white pants again. Additionally, there is a lesser known but equally important event that occurs each June: the opening of registration for the International Claim Association’s Annual Education Conference.
The International Claims Association has been dedicated to partnering with law enforcement to supply pertinent policy information in the course of criminal investigations that may have a financial etiology since 1999. As the Law Enforcement Inquiry Director (aka volunteer) I receive numerous inquiries from local, state, and federal law enforcement on a weekly basis asking for our members to assist them in looking for potential life insurance/annuity policy information that may be a critical turning point in their investigation.
Understanding and obtaining a claimant’s occupational duties and job functions are vital to claims adjudication and making the appropriate decision regarding the approval, or rejection of a disability claim. Assessing a claimant’s occupational duties, relevant worker characteristics, and day-to-day pre-disability job demands are essential factors in this determination. In fact, understanding the material and substantial duties of this occupation is at the very core of claims management in today’s environment.
The exclusion from accident coverage for loss contributed to by illness will only apply if the disease “substantially contributed” to the loss.
Disability claims based on multiple sclerosis or “MS” are challenging. An insurer must consider the claimant’s subjective symptoms and the medical evidence when assessing whether an insured’s functional capacity prevents him or her from performing occupational duties. The recent unpublished ERISA decision out of the Ninth Circuit – Kibel v. Aetna Life Insurance Company, __ Fed.Appx.__, 2018 WL 832870 (9th Cir. Feb. 13, 2018) – implies that an insured’s return-to-work efforts and subjective evidence should play a more significant role in an insurer’s analysis of an MS claim. However, careful scrutiny of the evidence not discussed by the Court suggests that it may simply have been looking for a way to award further benefits.
Greetings ICA members –
Our industry is facing a number of challenges. In recent years, competitive pressures, economic volatility and regulatory changes have required insurance carriers to operate more efficiently and be more resourceful than ever before.
In an effort to advance the ICA’s educational offerings, the ICA invites all corporate members to submit a proposal for a white paper and conference presentation that explore the same topic. Upon completion of writing assignment and necessary approvals, white paper authors will be granted one complimentary conference registration to present their white paper topic at the 109th Annual Education Conference.
Did you know the Coalition Against Insurance Fraud (“CAIF”) published a report on fraud in life and disability insurance? If you are not familiar with CAIF (www.insurancefraud.org), it’s one of many different web based resources available for claims professionals to locate information. As indicated by its name, CAIF focuses on fighting insurance fraud.
Whoever said the “dead tell no tales” was clearly unfamiliar with forensic claims. In cases of sudden or unexpected mortality, the humble death certificate can provide essential reading for the claims examiner often in conjunction with a police report or medical examiner’s report.
A billionaire tossed a verbal stone into an electronic pond, causing ripples worldwide.“ All these concerns about privacy tend to be old-people issues,” LinkedIn founder Reid Hoffman proclaimed about the new world of electronic communication.
Hello friends! Autumn has arrived and I hope you have the opportunity to enjoy some of the best the season has to offer. Whether it be watching football, huddling around a bonfire with friends, or enjoying everything that is pumpkin I hope you are able to make the most of the season.
In this update, we will summarize two recent California decisions, one on the bad faith defense of genuine dispute and one on E.R.I.S.A. We will also discuss a U.S. Supreme Court decision on E.R.I.S.A. If you have not done so, please provide us with your email address. Please contact us if you would like copies of any of the decisions discussed below.
Last October, the fraud predictive modeling team met… just as it had throughout 2017. We were all somewhat pleased. The model was running based on the data we had entered and positive information was being produced.
As a best practice, I recommend investigating all foreign death claims. Due to technological advancements, it is becoming easier for individuals to purchase or steal illegitimate documents. This doesn’t mean that I complete full investigations on all foreign, some are as easy as reviewing the documentation that is supplied. Other investigations can take months to complete.
Even though paper records for most medical practices have evolved to digital, all of that data currently resides in silos, where consumers attempt to reconcile data among their providers and health payors. This can be challenging, as there is no single source that identifies where all of an individual’s health data resides, let alone the order in which it was entered.