1. 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

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

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

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

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

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

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

8. Claim Management Claim adjudication vs. processing Caseload prioritization

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

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

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

12. Staffing Adjudicator empowerment Realistic and manageable caseloads Routine audits

13. QUESTIONS ?