Foreign risks in underwriting can result in foreign death investigations in Claims. Trends, best practices, and red flags for fraud will be covered in what will be a very interesting session. Foreign death case studies from an investigator's perspective will also be included.
Critical Illness claim adjudication is an important part of the risk management process. As such, it is important to recognize the unique skills required to properly adjudicate a Critical Illness claim so that the insurer provides fairly the benefits promised in the contract while protecting the insurer from paying claims for conditions outside of those intended and priced for.
This article is featured on page 26 of the September 2012 SOA Long Term Care Newsletter. Other articles in this issue include:
The Future of Genetic Testing is Now
Aspirin, Not Morphine
LTC Dashboard - Key Accessory to High-Octane Performance
Opinions and a Conversation on LTC Financing
Independent Providers: A Long-Term Care Insurance Conundrum
AGGIR, the Work of Grids
Thoughts of a Landscaper
As a result of the growing amount of information that is posted to social networking sites, claim professionals, and/or the experts they engage, have discovered that social media can be a useful investigative tool for conducting research and uncovering relevant information on claimants.
Just under half (47%) of new critical illness insurance claims in 2011 began prior to age 55 according to the 2012 Buyer & Claimant Study conducted by the American Association for Critical Illness Insurance (AACII) and General Re Life Corporation.
The ‘customer experience’ seems to be the buzzword of the moment in many of the world’s life, critical illness and disability insurance markets as the industry wakes up to the need for service as a differentiator in a competitive world, where products are largely commoditised and homogenised.
For several years now, claims professionals have looked across at their underwriting neighbors with a tinge of envy – while they struggle on with piles of paper and processes heavily dependent on manual input, many of those lucky underwriters get to play with sophisticated workflow and imaging systems, rules engines, tele-interviewing and a growing host of facilities that the claims folk can only dream of.
The author had a very interesting discussion with a claims investigatorat Celent’s industry networking event in London (How Digital and Social Innovation Challenge the Insurer Business Model—read a summary of the event here). He went into some detail about how they were using social media in their claims work.
The recent economic environment has led many to speculate that there has been an increase in suicide rates due to the economy. While it may be years before conclusive data is available for this economic downturn, historical data as well as a review of Swiss Re’s reinsurance data gives some insight into the current situation. This article examines suicide rates and some of the statistics that are available in the public sector as well as from Swiss Re’s claims experience in the United States in order to give some insight into this manner of death in light of our economy.
A life insurance agent wrote a $25,000 life insurance policy on a nine-month-old infant. In applying for coverage, the parents responded “No” to the following question:
Has any person proposed for insurance consulted or been seen by a physician, psychiatrist or medically licensed practitioner in the last five years, or has any such person ever been declined for life insurance or offered a policy with an extra premium charge?
Three months into the policy, the infant passed away. Upon investigation of the claim, the insurer discovered that the child had been confirmed as having a terminal condition within days of the application being submitted for coverage. The parents had been advised of the probability of their child’s condition on February 22, and received test results confirming the diagnosis on March 3. They then applied for life insurance on the child on March 8. When the claim was tendered later that year, the life insurer denied the claim due to the material misrepresentation on the application.
An insurance advisor was asked to procure life insurance policies for two business owners who were in the process of obtaining an SBA loan. As a prerequisite for the policies to be put in place, both clients would need to submit to examinations with coverage contingent upon the exams outcome. The application also required the advisor to confirm by checking a box “YES” that his clients had been advised of the conditional nature of the binder and that no coverage was in force until exam results were approved by the insurer. The agent checked the “NO” box. The clients signed the application, paid the initial premium and were provided copies of the Conditional Receipt.
A month later, one of the applicants suddenly died before the medical examination was completed. The insurance company denied the claim for the $250,000 life benefit citing the terms of the “Conditional Receipt.” In short order, a suit was filed against the advisor.
Much has been published in the mainstream media about the fact that disability income insurance claims have increased dramatically over the last several years, along with a disproportionate number of inappropriate claims denials. And the claims departments of many insurance companies have been told to “tighten-up.” Claims that would have once been routinely paid are now being denied due to industry trends, misunderstandings, lack of consumer knowledge, inability to contest, and lower returns on investment.
Every day Americans rely on their bones and muscles for strength, energy and mobility to help them get their job done. But research by The Hartford Financial Services Group, Inc. shows workers' framework is showing wear and tear.
The popularity of the multiple CSI television shows and similar real-life (and death) cable programs have raised the public's awareness of forensic science. Insurance companies have also noticed and forensic claim investigations are becoming a normal part of the business, especially in the area of AD&D claims where it is important to determine if a death was accidental according to the terms of the policy.
It seems that everyone is interested or at least has heard of Facebook, Twitter, My Space and other social networking sites. Undoubtedly, they are becoming more and more populari and bringing the world in which we live closer together. These new networks provide an overabundance of possibilities to keep "friends" (real or virtual) informed of our daily status, our activities and even our whereabouts should we chose to do so. This level of sharing has led to the creation of an electronic evidence trail of a user's thoughts and activities including photos as created and recorded by the user. Insurance companies have caught on and have started to "surf" the web to gather information with respect to claimants as part of the claims adjudication process. Telephone interviews and video surveillance do not seem to be enough anymore.
The role of a contestable claim examiner in a life insurance company is fraught with challenges and pressure. Properly managing contestable claims can mean additional time and expense, and the cost savings from taking shortcuts is far outweighed by the costs of making claim decisions without a thorough understanding of the facts.
It's a fact that disability income insurance (DI) claims have increased dramatically over the last several years, along with a disproportionate number of inappropriate denials. The claims departments of too many insurance companies have been told to "tighten-up." Claims that once would have been routinely paid are now being denied due to industry trends, contractual misunderstandings and consumer lack of knowledge and inability to contest.
The Early Duration Claims Survey Subcommittee of the Society's Committee on Life Insurance Mortality & Underwriting Surveys has completed their report on the results of a survey on life insurance claims in early policy durations.
The largest open long-term care insurance claim has surpassed $1.2 million in paid benefits, according to a just-released report from the American Association for Long-Term Care Insurance. The claimant, a woman, purchased coverage at age 43, paying an annual premium of $1,800. Three years later her claim began and has continued for almost 12 years. [Note: Payment of policy premiums ceases when an individual is receiving policy benefits.]
To spot a trend in clothing, you check out the fashionista as they flicker about with flair and flash, but how do you discover trends in group disability? I’ve yet to meet a case managerista and I am not really sure I want to (I’ve heard there might be a few in Toronto), says ING Re's Mark Taylor.