- Once the adjudicator understands the individual’s occupational and employment circumstances, RGA suggests immediate engagement of the insurer’s own internal rehabilitation or recovery specialists or a dedicated case manager to determine what (if any) rehabilitative services are potentially suitable. This may include the provision of the following services, to name a few:
- Assistive devices and equipment (including working-from-home devices/equipment and personal protective equipment)
- Identification of duties able to be performed
- Negotiation of hours/duties/location with an employer
- Business coaching
Current Claim (Partial Disability)
COVID-19, while having the potential to significantly affect the health of anyone, presents a higher risk to those who are immuno-suppressed or immuno-compromised. As a result, it may be that individuals who have returned to work in a partial capacity may, in this situation, revert back to being certified totally disabled for their own safety.
When a customer who was ‘partially disabled’ becomes ‘totally disabled,’ RGA recommends contacting the customer and asking questions to determine the cause of the certification change. It is important to refrain from making assumptions until the cause is known as it may be that the reduction is the result of being at ‘higher risk’ or it may just be a consequence of the deteriorating labor market. Either way, it is important to know the cause and, where possible, to seek medical verification that any reduction was medically indicated, as some occupations and occupational duties may allow an individual to remain productive and ‘at work’ by changing the environment in which they work and the manner in which they undertake their work.
Once the claims adjudicator understands the cause, RGA encourages the use of the insurer’s internal rehabilitation specialists, where appropriate, to determine if there are any solutions to keep the insured at work while maintaining their safety. In the event this is not possible, all efforts should be focused on retaining the insured’s employment during this hiatus (if the customer is an employee) or solutions to keep the business operating (if self-employed), while at the same time seeking to minimize potential physical or psychological deconditioning. RGA believes that these steps are an important protective mechanism for the customer.
It is important to note that the above scenario does not apply to customers that are able to work and were at work at the start of the pandemic and not receiving partial benefits, irrespective of an underlying health condition or status.
Current Claim (Total Disability)
As previously mentioned, the best mechanism to support customers through this pandemic is to keep their recovery on track and, where possible, keep them employed and/or their business afloat. In the absence of employment, supporting individuals to return to work with a new employer or commencing a new business will be extremely challenging. That said, it should not deter claims adjudicators from their usual claims management practices of assessing a customer’s eligibility to claim disability benefits per the policy terms and conditions.
With many health and treatment providers adopting telehealth in an attempt to provide a continuum of care and while treatment for some individuals may be delayed, it is hoped that for the most part customers will receive necessary and timely treatment to aid their recovery. In the event treatment has stalled, claims adjudicators should explore the reasons for this in more detail as there may be a workaround that has been overlooked. Where telehealth consultations are taking place, insurers can use them as an opportunity to engage with the providers and customers about treatment.