2009 General Meeting ● Assemblée générale 2009 Ottawa, Ontario ● Ottawa (Ontario) 2009 General Meeting ● Assemblée générale 2009 Ottawa, Ontario ● Ottawa (Ontario) Canadian Institute of Actuaries Canadian Institute of Actuaries L’Institut canadien des actuaires L’Institut canadien des actuaires Session/séance : Group LTD Claim Audit Findings Speaker(s)/conférencier(s) : Kevin Braybrook

Presentation Outline Background Initial Liability Decision Claim Management Change of Definition Staffing

Background Common LTD Claim Audit Findings LTD Claim Audit Focus: –Initial Liability Decision –Claim Management –Change of Definition

Initial Liability Decision STD to LTD transition Eligibility Verification: –Covered member; –Actively at work; –Prior Carrier; –Proof of age; –Pre-Existing Condition Investigation.

Initial Liability Decision Accurate Benefit Calculation: –Verification of prior earnings; –Reduction of benefits to match billing statements; –All Source Maximum Calculations.

Initial Liability Decision Job Description and Physical Demands of the job Internet Searches Initial telephone interviews

Initial Liability Decision Review coverage information Disability definition verification Medical: –Over “medicalizing”; –Timing; –Medical Consultant making claim decisions. Appropriate Offsets Acceptance Letters

Claim Management Claim adjudication vs. processing Caseload prioritization

Claim Management Claim management plans – Short-term focused; – Next steps; –“Checklist” approach.

Claim Management Claim management tools: Independent Medical Examinations; Functional Claim Evaluations; Surveillance; Home Visits; Rehabilitation; Lump-sum settlements.

Change of Definition Similar to initial liability decision Timing of investigation Medical documentation Document decision

Staffing Adjudicator empowerment Realistic and manageable caseloads Routine audits

QUESTIONS ?