Pre-Existing Conditions
For Plans sitused in this state, the Pre-existing Condition provision is interpreted as a limitation rather than an exclusion, meaning if a disability is due to a Pre-existing Condition benefits will be tolled until the Pre-existing Limitation Period is met.
What is New York?
When reviewing whether an Evidence of Insurability investigation is needed, this portion of the Plan will need to be reviewed to determine whether the EE is a late entrant.
What is Waiting Period?
This system is where statistical, demographic and financial information is input. Benefits are issued through this system based on structure and information input by the claims specialist.
What is Intellis or Catalyst?
This field, which is part of the Actively at Work review, may require follow up with the employer for specific information regarding scheduled days off, approved vacation time and possibly other types of approved leave such as FML.
What is: If gap between DLW (date last worked) and DDC (date disability commenced) explain?
This is the only source utilized to obtain coverage information that is missing or requires validation.
Who is the Employer?
This is the period (typically noted in months) representing the length of time following the claimant's original insurance effective date or benefit increase date that the Pre-existing condition applies. When documenting the provision, it's the last number listed.
What is the Pre-Existing Limitation Period?
If it is determined that an Evidence of Insurability investigation is needed, you will reach out to your UL or CSS to assist in reviewing information including underwriting's determination, past medical information for up to 12 months prior to the approval for coverage, and this information.
What is the Statement of Health Application form?
This system is a repository for claim-related images that have been scanned from mail, fax or email. Information can be tagged for future reference.
What is Storage Image Retrieval (SIR)?
If the certificate/Plan does not contain this option in the Schedule of Benefits, it will not apply. Information regarding whether this portion of the template applies to your specific claim may be obtained via UIS or ER statement, coverage codes, and plan language.
What are the Buy up fields?
This is the group of employees covered under the Plan. It may be defined in many ways such as full time/part time, location/division, union/non-union, occupation, etc.
What is Eligible Class?
This is the period (typically noted in months) representing a period in which the claimant has not had treatment between the insurance effective date and benefit start date. If this period is satisfied, the Pre-existing Condition provision will not apply. When documenting the provision, this is the second number listed.
What is the Treatment Free Period?
Other names for this provision may include Evidence of Good Health, Statement of Health, or Statement of Good Health.
What is Evidence of Insurability?
This system is used to obtain employee data, date of hire, salary information, and coverage information including insurance effective date, report number, subcode and subpoint/branch.
What is Unified Inforce System (UIS)?
This document must be reviewed in order to assess whether investigations are needed for template fields including Eligible Class, Actively at Work, and Evidence of Insurability and Pre-existing Conditions for both core and buy up coverage.
What is the Certificate (Plan)?
This provision must be reviewed to verify that the claimant was either performing the duties of their job, had regularly scheduled days off, or was on an Employer-approved vacation, holiday or business closure. It's reviewed in conjunction with the Date Your Insurance Ends provision to ensure that EE's coverage was in effect when their disability commenced.
What is Actively at Work?
This is the period (typically noted in months) immediately prior to the insurance effective date or benefit increase effective date that needs to be reviewed during a Pre-existing condition investigation to determine if the claimant received medical treatment, consultation, care or services, took prescribed medication or had medications prescribed. It is the first number listed when documenting the provision.
What is the Look Back Period?
This provision sets forth a timeframe during which coverage can be contested with the medical underwriting unit if it is found that information provided on the Statement of Health application was incomplete or inaccurate. The standard timeframe is 2 years. If beyond this timeframe as of DDC, no investigation is needed.
What is Incontestability: Statements Made by You?
This system is utilized to document claim information such as coverage verification, phone calls, action plans and decisions. It is also utilized to schedule future actions needed on claims.
What is Disability Process Automation (DPA) or Catalyst?
Information for fields including date of hire, insurance effective date for both core and buy up coverage, predisability earnings can be obtained from this system (assuming the customer provides information via electronic feed).
What is UIS?
This is the period of continuous membership in an eligible class required before coverage takes effect.
What is the Waiting Period?
This provision, also referred to as Continuity of Coverage or No Loss/No Gain prevents an employee's loss of coverage due to an employer's change of insurance carriers or implementation of an updated plan.
What is Special Rules for Groups Previously Insured under a Plan of Disability Income Insurance?
In order for Evidence of Insurability to be an eligibility requirement, the Plan must meet both of these requirements.
What are Fully Insured and Contributory?
This system is used to identify structure information such as coverage code and plan code, and to determine details on plan provisions.
What is Unified Disability System (UDS or Planmaster)?
Separate evaluations need to be completed for both core and buy up coverage to determine whether an investigation is needed under these provisions.
What are Evidence of Insurability and Pre-existing Conditions?
This template, required on all claims, contains coverage and eligibility information including date of hire, insurance effective date, date last worked, date disability commenced, actively at work, evidence of insurability review, pre-existing condition review, buy up information, and salary information.
What is Coverage Verification?