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Global Claims Views: Disability: RGA’s Claims Management

Pathway for Disability Assessment

TPD-long

The last couple of years have seen tough times for insurers and reinsurers active in the Australian market, and these have been widely reported both in Australia and beyond. There has been significant deterioration in disability experience particularly, impacting total permanent disability and group markets. Many insurers have reported losses and significant strengthening of reserves.

A range of changes are being discussed throughout the Australian market, in relation to product design and to the general approach to risk management practices.

One key element of RGA’s response to the deterioration in experience has been to initiate a paradigm shift in claims management. The aim is to move away from the traditional medically focused claims assessment model toward a more proactive, effective and holistic “best practice” model. It is hoped this will impact disability experience in a positive way for claimants and insurers and allow for an upgrade in current disability claims management capability.

To support this initiative RGA Australia has created a new training programme covering all aspects of disability claims assessment. The programme, called Claims Management Pathway (CMP), plays a crucial role in this paradigm shift initiative, assisting with implementing change and raising disability claims management standards across the industry.

 

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What is the CMP?

CMP is an all-encompassing claims assessment approach developed by RGA Australia to enhance the assessment processes for disability claims (total and permanent disability [TPD], income protection and group salary continuance). RGA has invested significant resources to create a model that is proactive and holistic, and moves away from a medically focused model that relied heavily on the treating doctor as a gatekeeper for claims decisions.

Most insurers’ existing claims assessment training programs are separate standalone modules; e.g. financial, medical, information-gathering, etc. Where CMP differs is that each training module flows into another and while each can still be undertaken as a separate session ultimately they work together, covering the end-to-end assessment process and providing a guide to best practice claims management.

CMP modules deal with the full term of the claim from notification through on-going assessment until termination. They include the following items:

  • Strategy setting: Claims assessors learn a holistic management approach, rather than a process-driven or reactive method of claims assessment, to achieve an appropriate and balanced outcome based on all relevant factors.
  • Duration management and risk profiling: The focus of this module is for assessors to utilize the information contained in the Medical Disability (MD) guidelines to predict the lifecycle and duration of a claim. The module aims to provide assessors with the skills and confidence to discuss return-to-work outcomes with claimants and their treating doctors while also improving their understanding of the claimed condition.
  • Functional assessment: Here the emphasis is on claimant abilities as opposed to inabilities, part of which focuses on the claimant’s bio- psychosocial factors. Assessors are given tools to break down the claimant’s pre-disability occupation into its key duties and to consider these in relation to a claimant’s functioning.
  • Use of medical and investigative resources: This module considers how assessors can communicate most effectively with treating doctors, with a focus on asking the right questions, building rapport and returning the claimant to work. In doing so, assessors can appropriately gather information directly from a treating doctor, hospital or allied health provider and get the most out of an independent medical examination.
  • Internet searching: The Internet is an important tool in claims assessment. This module identifies search techniques and information gathering from social media and/or other sites as part of the claims assessment process.
  • Effective use of surveillance: This module, which is still under development, is a web-based interactive case management simulation, designed to get assessors thinking about the purpose of their investigations and understand how they can be used in the most effective manner.

Another differentiating factor of the CMP is that the learning process does not stop at the completion of its training modules. Once assessors have completed a module, the lessons are reinforced and embedded with them through on-site RGA claims consultants, who assist assessors in applying their newly acquired knowledge to their day-to-day claims assessments. This on-site support is provided in the form of one-on-one claim file reviews, case conferences and file discussions.

What value does CMP add?

By combining the training with on-site support and coaching, the application of these best practice principles continues to be reinforced. In addition, the focus on setting strategy and placing greater emphasis on capability and bio-psychosocial factors should enable insurers to support claimants in earlier and sustained return-to-work outcomes, leading to shorter claim durations and reduced benefit payments.

What has been rolled out?

To date, RGA has rolled out the following modules to more than 800 participants from clients across Sydney, Melbourne and Brisbane:

  • TPD Legal Concepts
  • Use of Medical and Investigative Resources
  • Strategy Setting
  • Duration Management and Risk Profiling
  • Functional Assessment
  • Internet Searching
  • Serious Game (an interactive instructional game for claims assessors)

We are continuing to develop online training modules for effective use of Internet searches and surveillance, which will be available in 2015 for assessors to use as a reference tool.  



© 2015 Reinsurance Group of America, Incorporated (RGA). All rights reserved. No part of this publication may be reproduced in any form without the prior permission of the publisher.

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RGA has made all reasonable efforts to ensure that the information provided in this publication is accurate at the time of inclusion and accepts no liability for any inaccuracies or omissions.

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The Authors

  • Jaya Aiyappan
    Claims Specialist Support
    Team Manager

    RGA Australia
  • Peter Barrett
    LLB, FCII, FAMS
    Global Head of Claims, 
    RGA UK
    Send email > 

Summary

This article summarizes RGA's Claims Management Pathway (CMP), which assists in implementing change and raising disability claims management standards across the Australian industry.
 
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  • claims investigation
  • large claims