Assessing disability claims can be a culinary art sometimes...
... You have to mix the right combination of several ingredients to bake a delicious cake, or in the case of a disability claim… a delicious decision!
Contrary to the stereotype of claims being automatically denied, in claims administration, the job of the Claims Adjudicator (adjuster/case manager/assessor) is not just about making decisions based on days of the week or moods or the luck of the draw.
It is to review all evidence and use a combination of skills (medical, legal, financial, occupational, etc.) to arrive to a fair decision in the quickest time possible.
At the same time the adjudicator must maintain the trust of the claimant and manage expectations from advisors, employers, managers, etc. Not an easy task…and to complicate matters, let’s not forget that the Claims Adjudicator is dealing with humans, and human beings are all unique and react to adversity in different ways. For example, a claims department may use reasonable recovery times as guidelines for return to work, but the truth is…individuals have different pain tolerances, mind sets, motivations, and emotional IQ’s. Therefore, an insurer's claims experience and ultimate recovery guidelines are not the same for all.
In my many years of claims adjudication, I have learned that the claims on my desk could not be treated simply as files; but rather as someone’s personal, individualized story. Therefore, I found that close interaction with the claimant was ALWAYS the best practice.
- It allowed me to gain a better understanding of their personal story.
- It assisted me with connecting the dots, or completing the puzzle.
In my experience, I have found that most claimants do wish to go back to work as soon as possible, but have to deal with many barriers. Therefore, time is of the essence during this small window of opportunity.
Take a look at this chart:
Published in 2005 by the American College of Occupational & Environmental Medicine.