Claims

​RGA International Health Briefs: Cancer Treatment

The treatment of cancer is undergoing a major period of research and development with new treatments being introduced on a regular basis. Many of these are very expensive, with the cost of some new drugs running into tens of thousands of dollars. Cancer is highly emotive, with patients eager to benefit from the latest medical advances. It is therefore important that health underwriters and claims assessors have knowledge of these treatments.

This article introduces some types of treatment being used to combat cancer today. In future articles we will more fully explore each treatment type.

Foreign Deaths - Essential Tools For Your Investigation

Managing claims involving deaths outside of the United States is a unique challenge for insurers and the claim professional. Foreign deaths are often more complex, and the risk of fraud is much greater than domestic death claims. This requires the collection and analysis of information that may not be necessary for other claims. One tool that can be used to assist in the collection of information necessary to analyze a foreign death is the Foreign Death Questionnaire.

​Anatomy of Homicides - An Overview (RGA)

This article will attempt to address such questions as: Who are homicide’s victims and offenders? Why is the U.S. murder rate several times higher than that of other wealthy countries? Why are fewer homicide cases being solved? What significant factors correlate closely with murder rates? And what impact does homicide have on life insurance claims?

Suicide: Global Insights and Insurance Analysis (RGA)

Currently, suicide stands as the 13th leading cause of death worldwide, responsible for nearly 1 million fatalities annually. RGA’s Global Research and Development team’s analysis of suicide rates before and after the 2008 financial crisis uses population data from Canada, Australia, the UK and the U.S., as well as insured data from RGA’s extensive database.

This paper presents the results of the research, as well as information about treatment of suicide claims in these markets.

Mental Health Claims: Time to Think Differently

This article will explore and discuss the immediate issues that need to be considered in a life insurer’s claims department, as well as give a practical guide to developing a partnership and support model for the management of subjective claims.

Risk Insights March 2014 Edition (Gen Re)

Articles in the latest issue of Gen Re's Risk Insights include:

- No Easy Way Out: An Overview of International Trends in Suicide
- Suicide: Right to Die, Wrong to Claim?
- South African Group Mortality Experience
- Paying Assisted Death Claims - A UK Perspective

Why Social Media Likes Disability Claims Assessors

A photo of a young man enjoying himself snowboarding is posted online on a social networking site. Nothing unusual in that – hundreds of thousands of photos are shared in this way every day. The difference here is, this man is currently receiving disability benefits under an Income Protection (IP) policy, claiming that, following an accident at work, he suffers widespread musculoskeletal pain causing significant functional limitation.

Foreign Travel - Foreign Claims

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.

Completing the "Claim Story" Using Social Media

The lead article in the June issue of Munich RE's Connections.

Transforming Underwriting and Claims Management Practices

This article by Kim Cohen for the April/May issue of RiskeBusiness explores the way medical and information technology will impact underwriting and claims practices over the next decade.

Underwriting Guide to Synthetic Cannabinoids

This paper aims to provide what underwriters and claims examiners need to know about this ever-expanding aggregation of synthetic drugs that are luring users with their enhanced Cannabis-like effects.

Suicide Trends in an Insured Population

This and other articles are featured in the latest issue of SCOR Global Life's The Messenger. Other articles include:

Mortality by Band - An Update
Using Financial Tools to Manage Longevity Risk
Toledo to lead SCOR Life Brazil

Underwriting and Claims: From the Outside Looking In

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

Social Media - Another Item for the Claims Toolbox

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.

Nearly Half Of Critical Illness Insurance Claims Begin Prior To Age 55

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.

Automated Processing Pays Off

Health insurers are counting on technology to reduce the claims-processing errors that cost billions of dollars and frustrate patients and physicians.

How to Build a Modern Claims Experience

Claims have become the next battleground for winning and retaining customers, and insurers are exploring new ways to apply people, process and technology to create a superior customer experience

Claims and the Customer Experience

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.

Underwriting and Claims System Integration

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.

Asia-Pacific Underwriting & Claims Watch (Scor Global Life)

An Introspective View of Retrospective Underwriting

Making Social Data Operational

New report examines how insurers can employ data from social media sites in claims and underwriting.

Doctor, Patient, Insurer: The Impossible Triangle

Recently I have been touting the idea to disability insurers that it would be productive for senior doctors representing insurers to visit treating doctors in their surgeries.
 

Conquering Claims Challenges

Personal health, life, and P&C insurers face myriad claims challenges, and many are using technology to overcome them.

Defying History

The incidence of longterm disability claims is little changed since 2007, despite its tendency to rise in recessions.

Insurers vs. Consumers: How to Implement the New Appeals Law

It’s not the first time that insurers and consumer groups have battled it out, but the recent face-off over PPACA’s provision allowing consumers to appeal coverage denials looks to be a big one.

Claims Investigations Using Social Media

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.

Disabilities, Claims on the Rise

Despite the increase, the Council for Disability Awareness says there's little evidence the recession has broadly impacted the number of claims.

Trends in Suicide Claims

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.

The Case of the "Questionable Answer"

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.

The Case of the Faulty Conditional Receipt

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.

What You Need to Know About Disability Claims Definitions

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.

Health-reform Regs Overhaul Claims Appeals Process

The government released interim final regs aimed at creating a system of checks and balances for internal and external appeals processes of health claims.

Health Insurers Often Fail To Process Claims Correctly

It's no surprise when health insurers deny a claim or pay only for a certain "reasonable" amount.

It has become a way of life. But we should expect health insurers to process our claims properly and accurately.

In reality, one in five medical claims are processed inaccurately by health insurers, according to the 2010 National Health Insurer Report Card by the American Medical Association.

Claim Reserve Run-Out Studies: The Method and Its Application to Long-Term Accident and Health Product Reserve Adequacy Test

When talking about valuation in the United States, people have a feeling that it is all about government prescription.

UNUM: Pregnancy, Cancer Lead Disability Causes

Cancer and complications from pregnancy were the top causes of long term disability claims filed with Unum Group Corp. in 2009.

Out Of Joint: The Hartford's Research Shows Aching Backs, Worn-out Knees, Painful Feet Keep Many Off The Job

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.

An Introduction to Forensic AD&D Claim Investigation

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.

Making Wine and Claim Audit Design

Just as with a disability claim operation, new varieties of grapes require intensive quality assurance practices.

Using the Web for Claims Investigations

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.

Suicide Claims within the Contestable Period: Separating Myth from Fact and Employing Best Practices (Swiss Re)

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.

Disability Insurance: Claim Denied

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.

Early Duration Claims Survey Report

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.

IBI: Job Loss May Sow Seeds for Future Claims - Core Protection Products - Life and Health Insurance News

Rising unemployment rates could lead to an increase in morbidity and mortality rates even for workers who keep their jobs.

NEW STUDY EXAMINES LONG-TERM CARE INSURANCE CLAIMS

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.]

Emerging Technologies Fight Claims Fraud

Industry insiders discuss emerging technologies, including predictive modeling and other tools, that allow special investigations units to be more proactive in addressing fraud.

LTC Claims Management of the Future

Presentation at the SOA Annual Meeting & Exhibit, October 2008.

Trends in Group Disability – Trying to Stay Ahead of the Curve

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.

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