For decades insurance companies have promoted how they incorporate an “Early Intervention” approach to managing disability claims, yet there has been no tried and true approach or process that I am aware of which has been been continuously and effectively incorporated on every claim. I’m not saying that there haven’t been advances made in proactively managing claims. Moreover, from a claims perspective we have advanced in our knowledge of introducing and utilizing skilled resources such as Medical consultants and specialized rehabilitation consultants to assist us with our understanding of the disability and developing appropriate return to work plans wherever possible.

Forty years ago the majority of disability claims received were primarily comprised of measurable physical illnesses which followed the usual recovery period as identifed by the medical professionals and benefits were paid in accordance with the respective recovery period. Claims of a psychiatric nature were not totally absent, but were not so prevalent. Today psychiatric illness represents the largest percentage of disability claims and/or serve as a secondary condition which is indirectly prolonging an individual’s usual recovery period.

Disability management can no longer be the responsibility of the Insurance company alone or begin once the employee stops working. Disability Management needs to start before the employee stops working.  Many insurers and rehab companies are  promoting how they have successfully reduced claim durations through a proactive approach of meeting with the employee within the first few weeks of their absence.  While this is a positive step for both the employee and employer, there’s more that can be and is being done.

More and more employers are seeking help from their EAP programs and their insurers in helping them introduce or expand their  Health & Wellness programs in helping them reduce disability claim incidents through prevention.  A recent article in Benefits Canada Magazine by Rebecca Smith of Medavie Blue Cross has in my opinion eloquently and succinctly captured the challenges we’ve faced in disability managment and provides examples of how an Integrated Approach between Employers and Insurers can have positive benefits for all.  Ms. Smith notes:

“The demand for wellness and disability solutions—and for prevention and intervention strategies—will continue. But while employers are beginning to recognize the benefits of integrated wellness management, the challenge lies in implementing, using and evaluating these approaches effectively.”

“Historically, case management took on a greater role once an employee was off for a period of time. Today, we recognize the importance of placing a stronger focus on these case management initiatives much earlier to reduce the number of days off, ultimately reducing longer-term disability claims and costs. With the right integrated approach to wellness—and the right structure—organizational and employee health is a reachable goal for all employers.”

You can read Ms. Smith’s entire article by clicking on this link: http://www.benefitscanada.com/benefits/disability-management/the-5-building-blocks-of-disability-management-24282

ou have likely noticed an increased emphasis by Rehabilitation companies who promote how they

THE CANADIAN PRESS

TORONTO – Although Michael J. Fox turned 50 this year, the boyish actor who charmed audiences in “Family Ties” and “Back to the Future” says his battle to find a cure for Parkinson’s disease keeps him young and too busy to feel ill.

The Emmy Award-winning star told roughly 2,000 people gathered at a North American health conference Tuesday that his condition appears to have plateaued and that once-severe episodes of Dyskinesia — a movement disorder that causes him involuntary tremors and sudden jerks — have diminished.

Accepting the disease and surrounding himself with like-minded supporters have helped him thrive beyond many people’s expectations, he said, noting that anyone in a similar situation can do the same.

“You have to empower yourself, acknowledge what the situation is, acknowledge what your goal is and just move toward it,” Fox said at the HealthAchieve conference, an annual three-day gathering that draws more than 7,000 delegates from Canada and around the world.

“And that quest keeps me young, it keeps me involved. I don’t have time to get worse.”

In addition to promoting his work with the Michael J. Fox Foundation for Parkinson’s Research, the actor-turned-activist said he still enjoys performing, and drew applause from the crowd when he mentioned recent appearances on “The Good Wife” and “Curb Your Enthusiasm.”

Fox said he’s open to adding more TV roles to his resume and said he wouldn’t even rule out a return to the big screen, if the film project was right.

“I’m open for whatever’s out there,” he said to an enthusiastic crowd that greeted him with a standing ovation and offered another at the end of his 30-minute speech and about 20 minutes of questions.

“A movie would be a big undertaking but who knows, we’ll see what happens.”

Peppering his keynote address with humour-filled tales from his childhood in Canada, his ascension in Hollywood and his recent role as one of the world’s foremost advocates for Parkinson’s research, Fox stressed his positive outlook as the key to carrying him through life’s toughest moments.

Fox was just 29 when he was diagnosed with early-onset Parkinson’s, a degenerative neurological disorder characterized by progressive loss of muscle control.

He had noticed an uncontrollable tremor in his pinkie finger while shooting the 1991 film, “Doc Hollywood,” but refused to believe he was ill — after being told he had Parkinson’s he sought a second, then a third and a fourth opinion. He says it took him years to accept what doctors were telling him.

“It was kind of like being stuck in the middle of the street with your feet in concrete, unable to move and you know a bus is coming,” said Fox, who shot to fame by portraying cocky young Republican Alex P. Keaton on “Family Ties.”

“You don’t know when and you don’t know how fast it’s travelling, you feel its vibrations but you don’t know when it’s going to hit.”

For years, he kept his condition secret, sharing it only with his family. He admits he feared how fans would react, and therefore waited until the third season of his sitcom “Spin City” to publicly acknowledge he was ill.

“Timing in a joke depends on the audience being with me and I didn’t think they’d think I was funny if they knew I was sick,” says Fox, who moved side-to-side as he read notes from a podium, his speech occasionally slurred and his head often cocked to one side.

But Fox says he was astonished when other Parkinson’s sufferers embraced him as an inspiration, and dedicated his life to raising awareness and finding a cure.

He created the Michael J. Fox foundation in 2000 and says it has handed out $250 million in research funds. Roughly $10 million has gone to Canadian projects, he says.

During a question-and-answer period after the speech, one health-care worker asked how to encourage patients to adopt Fox’s positive outlook.

Fox stressed that each patient has their own journey to follow, and cautioned loved ones against imposing their perceptions about how patients should cope.

“Even with caregivers and people that love and care for them, they project stuff onto them and the patient ends up feeling that way,” he says, recounting a story about a woman who complained her husband was in denial about his Parkinson’s because he spent his time golfing and skiing.

“Acceptance doesn’t mean resignation, it just means acknowledgment of the truth,” he says.

“That was important for me, to realize that I was still me. I was me, plus this challenge. And it didn’t have to eat a big part of me.”

Fox said he sees his life as one of possibilities.

“It’s the refutation of the idea that your fate is locked and the outcome of your life is certain,” he says.

“You may feel you’ve been cast in a tragic role but it’s really all about how you play it.”

INDEX: LIFESTYLE HEALTH FILM ENTERTAINMENT TELEVISION
Visit
thecanadianpress.com for more services from The Canadian Press, Canada’s trusted
news leader.

“I am very happy with the way my claim has been handled!” As an outside
consultant who gets it straight from the claimant’s mouth, I often hear many comments
like this about the people who are making the decisions on their claims. One interesting
aspect of my job as a Field Representative is that I deal with many different adjudicators
from various companies. Not only do I get some perspective on the adjudicators’ habits
and abilities myself, I also quite frequently get unsolicited comments and feedback from
the claimants. These comments are mostly positive ones.

Negative comments (which I really don’t want to dwell upon) are usually as a
result of poor contact and communication with the claimant. I often note that the
simplest of actions can make such a difference on relationships with case managers
and claimants with very little extra effort. Even if the decision about the claim itself
might be disappointing, claimants will at least understand the decision and accept it
even if they don’t like it. They respect the person and organization they represent and
understand why a decision is made. Generally (and there are always exceptions),
above average communication and communication skills with claimants render good
relationships, less adversarial situations and therefore less litigation. Little things like
picking up the phone and keeping claimants up to date on the progress of their claim,
goes a very long way especially if the decision is delayed for any reason. Doing phone
interviews may seem like extra work however, it is proven repeatedly that doing a little
bit of extra work initially will ultimately mean successful closure rates, better early
intervention and return to work success and less legal costs.

When contemplating this article, I wanted to solicit a few expert opinions from
colleagues I respect and admire in the Life and Health world. I began by asking them
what they felt were the best qualities of what makes a good claims case manager. I
didn’t want the usual jargon on formal education, past work experience and grammar
skills, but I wanted the personality traits and characteristics of successful case
managers. I wanted that “sixth sense” such experts have and what makes them
successful.

I asked this long winded question to Roula Sahyoun who I used to work with at
Unum Canada in the mid 1990’s and who is now at Munich Reinsurance, and Marg
Browne, Manager of Living Benefits Claims at Manulife Financial. When discussing this
with Roula, she noted that these qualities were the “Soft Skills” of a successful case
manager. On that premise, both Marg and Roula gave me what they thought made up
these qualities.

Marg has been a manager with Manulife for 12 years and has worked with many adjudicators
in a supervisory role. She also has over 20 years experience in the claims
business having handled her own block of claims for her first 8 years in the industry.
During my phone interview with Marg, she provided her take on these “soft Skills”:

“You want to be the nicest person you ever meet with a strong ability to say no!
The best adjudicators don’t necessarily need to have a lot of formal education. What I
like are people who have street smarts. I would prefer to have a street smarts person
over someone with only a formal education. I can teach the adjudicator formal skills like
understanding policies, medical information and accounting details, but I can’t teach
them insight and common sense.

I am looking for someone who has the ability to deal with the general public and
cope with all types of people and their personalities. The characteristics that make up a
good police officer are also common with the characteristics that make a good case
manager. They need to be compassionate at times, as well as inquisitive and have an
ability to ask themselves, “Does this make sense?” I want someone who has insight
about whether someone is telling the truth or not. It also doesn’t hurt to have a bit of a
mean streak!

As far as the formal qualities, I can teach them medical issues and we have in
house medical consultants as well. I can teach them about policy provisions
contractually and we have a team of lawyers to help if needed. I can teach them about
financial issues using our accounting consultants. But I cannot teach them insight and
common sense. The ability to look at a file and claim and recognize that something
might just not make sense or is not right. We have resources in place for the formal
things but not for the soft skills.

As a manager, I would encourage all adjudicators to always use fairness in
claims adjudication. Understand what it is like to be in their shoes (the claimants). Most
of the claimants you deal with don’t know or understand this process…”

MARG BROWNE
Manager Living Benefits Claims
Manulife Financial

Further to Marg sharing her thoughts on the subject, I had the opportunity to
speak with Roula, who provided her perspective Roula joined Munich Re in January
1998. Her responsibilities include overseeing a team of Account Managers and Claims
Litigation Director, performing regular claims reviews, producing analytical reports &
recommendations, consultation services and relationship management. Roula brings
20 years of experience in disability claims management.

Here is what she wrote:

Disability Claim Specialist’s Key Soft Skills

“* Self-awareness: maturity, understanding who you are, why you do things a certain
way, how you reach decisions and choices…
* Creativity, positivity
* Action and goal orientation
* Excellent communication (written and verbal)
* Critical thinking and negotiation skills
* Strong analytical skills and attention to detail and accuracy
* Sound prioritizing skills to deal with evolving tasks
* Drive for results with successful collaborations and team work
* Insight/Perception, Empathy
* Conciliation: non-confrontational, non-provocative
* Decision-maker
* Proactive leadership that can balance multiple stakeholder demands and energize the
team
* Return on investment mindset and bottom line focus

As the saying goes:
“Experience is inevitable, learning is not”
Rather than rely just on years of experience, a focus on soft skills is important. A
learning mindset and a thirst to always think critically but with empathy may be the
unique ingredients that make up the successful Disability Claims Specialist.”

ROULA SAHYOUN
Assistant Vice President, Disability Claims
Munich Reinsurance
Toronto, Ont.

I note a lot of common characteristics in both of these well respected individuals’
comments when offering what they feel are the “Soft Skills” of a good case manager.
As far as my observations, I couldn’t agree more! I am hopeful that these insights might
help you as you continue to manage claims in what can be challenging circumstances.
I welcome your comments, feedback and encourage you to send in any suggestions
you might have about the article or the position itself.

Answer from ELAINE HOBBS, CCRC, President of Hobbsability:
Qualified vocational rehabilitation counsellors use established protocols and procedures to help their clients return-to-work. We always start with attempting to return clients to work with their pre-disability employers. If this is not an option, the counsellor then looks at helping clients return-to-work with new employers: working closely with the clients to help them see the skills and interests they have to offer new employers, combined with adjustment and vocational counselling.

Most insurance clients are able to return-to-work without rehabilitation intervention. As a society, most of us identify ourselves and others by our work. Not only does work provide money to pay the bills, but it also provides us with routine, identity, social relationships, and purpose. That said, most of us want to return to work following injury or illness, and most of us have the supports necessary to do so. But not all of us…

When rehabilitation intervention is required, we need to understand that it is not always the impairment that is preventing the client from resuming work: it is often the other “things” that the client used to be able to cope with before the injury or illness. The impairment becomes the straw that broke the camel’s back. The role of the rehabilitation counsellor is to help the client identify those ‘other’ factors, so that the barriers can be removed, and clients can get on with life, and work. In the absence of complex formulas involving recovery times, red flags, diagnoses, and educational and work histories, the best that I can do to advise you when to initiate vocational rehabilitation, is to share with you some of the questions I consider when reviewing files for intervention:

1. Does it appear that the client can easily return-to work of his/her own accord?
2. Are there straightforward diagnosis and treatment, clear recovery times and prognoses?
3. Has the client expressed his/her realistic thoughts on when/how to return-to-work
4. Has the employer demonstrated a willingness to return the client to work?
5. Is there a clear time frame for return-to-work? If the answers to these questions are no, then now is a good time to initiate rehabilitation… the earlier the intervention, the better the rehabilitation outcomes.

Waiting until a client achieves maximum medical recovery rarely serves anyone’s best interests: by then, the client has thoroughly adapted to a disabled lifestyle, and is likely so far removed from the workplace, that he/she now fears a returnto work. Qualified vocational rehabilitation counsellors will help the client plan for a return-to-work, while he/she undergoes treatment and medical investigation. The rehabilitation counsellor can help the client identify the barriers to return-to-work, so that the barriers are removed, and return-to-work negotiations can commence at the earliest opportunity. Counsellors will also commence alternative vocational planning in more difficult situations: working with the clients to identify suitable, sustainable and realistic vocational options, in case they cannot return-to-work with the pre-disability employer, at the appropriate time.

Losing your job is frightening. Losing your job when you have a physical or mental health impairment is all the much more difficult. Not only do you no longer have a routine, a coworker network, a paycheque, autonomy, etc., but you also have to compete against ‘able-bodied’ candidates for new work, while living with pain, function loss, and/or fear of relapse. Vocational Rehabilitation Counsellors support clients through these difficult times, enabling them to resume function and work.

Elaine is the President and inspiration behind hobbsability Vocational Rehabilitation Services. Led by Elaine, hobbsability brings together a skilled group of highly trained and experienced professionals covering all relevant sectors of the vocational rehabilitation profession.A Canadian Certified Rehabilitation Counsellor (CCRC), Elaine founded hobbsability to provide rehabilitation services that are professional, unbiased and well – real. Elaine has served as Director of the Vocational Rehabilitation Association of Canada and as President of the Ontario Society. She acted on the Ontario Ministry of Finance Task Force on Accreditation, and has taught vocational rehabilitation and counselling courses for Seneca College. Servicing clients throughout Canada, all hobbsability professionals bring their real life experience, understanding and commitment to their clients, accounts and the company vision. hobbsability believes that in the real world, rehabilitation must honour each client’s unique circumstances. It is a vision that leads to credentialed expertise for lawyers, cost savings for insurers and employers, and realistic, sustainable return-to-work and function for clients. For more information on hobbsability visit their website www.hobbsability.ca

On September 21, 2010 Bell launched an unprecedented campaign called “Let’s
Talk” committing $50 million to help enhance awareness and understanding about mental
illness and to help support community organizations across Canada. What Bell started is a
positive step in the right direction. You can see what Bell`s doing by visiting their website
http://letstalk.bell.ca/initiatives-anti-stigma/

Following Bell’s “Let’s Talk” initiative, we have dedicated part of our site to Mental Health where
we will be sharing links to articles and information on mental illness and wellness.

I would like to launch this site by referring you to the Centre for Addiction and Mental Health
(CAMH) website and the statistics on mental illness where it’s noted that mental illness is
the second leading cause of human disability and premature death with an estimated cost to
Canadian economy of $51 billion in terms of health care and lost productivity. Most notably is
the statistic that 500,000 Canadians are absent from work every day due to a psychiatric illness.
Here’s the link to CAMH where you can review all the stats. They also have an online library
where you can find links to lots of information. Here’s the link:
http://www.camh.net/news_events/key_camh_facts_for_media/
addictionmentalhealthstatistics.html

There was also a very powerful and extremely personal show featured on Canada AM where
individuals and families came together to share their stories on suicide. Statistically it was
communicated that approximately 3600 people commit suicide each year in Canada and that
suicide accounts for 24 percent of all deaths among 15-24 year old Canadians. It was noted that
suicide is the second leading cause of death for Canadians between the ages of 10 and 24. You
can learn more from going to Canada AM’s website where you can also watch the interviews.
http://www.ctv.ca/CTVNews/CanadaAM/20111003/suicide-series-facts-statistics-111003/

No matter your age mental illness can affect anyone. Chances are someone close to you right
now is experiencing depression and you wouldn’t even know. Mental illness remains a dark
place where people still struggle to admit they need help, because most people are still afraid
to talk about it. A psychiatrist once told me that CAMH was the only hospital without a gift shop
because so few people visited patients there.

These are just two items I thought you would find of interest as we kick off our site. We will
update the site weekly, doing our best to bring more articles and information to you each week.
There is so much to be learned and so many opportunities to help implement change. We hope
you will join us in keeping the dialogue alive and invite you to submit any articles or suggestions
on how we can collectively work together in the continued need to raise awareness and
understanding on mental health; while at the same time enhancing and expanding our ability to
manage psychiatric disability claims including how to positively help the claimant return to work.

Until next week,

Lynn

Answer from RUDY WIETFELDT of HappySolutions.net:

This is a great question! There is no doubt that the current gold standard for either the treatment of major depressive disorder or an anxiety disorder is some combination of medication and psychotherapy.
Research trial after research trial has shown that depression, for instance, is best treated when medications and psychotherapy are used concomitantly. Interestingly, brain imaging studies have shown that while medications work from the base of the brain upwards, psychotherapy works from the cerebral cortex down towards the brain stem.
Cognitive Behavioral Therapy (CBT) is the most commonly practiced form of psychotherapy today. Recall that treatment using talk therapy really began formally with Freud’s dynamic therapy about a century ago.
There are three basic branches of psychotherapy: Cognitive, Behavioral, and Dynamic.Then, of course, there are divisions in consideration of the modality: there are individual therapies, couple therapies, and group therapies. All in all, there are literally hundreds of specific therapy types.
CBT has evolved over the past three decades from a variety of types of cognitive and behavioral therapies and is very popular because it can be useful to quickly treat a wide variety of symptoms and conditions.As such, practitioners may favor more of a cognitive or more of a behavioral slant in treating clients.The overall thrust is to help people see the relationship between Thoughts, Feelings, and Behaviors. Homework assignments are provided to help individuals practice to both think and act differently. Sessions typically last an hour, occur once per week, and run up to about 12-20 weeks, depending on the nature of the problem.A quick rule of thumb: the longer the problem has been present, the longer the therapy is required to stabilize the situation.
There are critics of CBT who insist that all forms of psychotherapy are generally effective; they go on to complain that data and reports supporting the efficacy of CBT end up costing the reputation of other valid, efficacious forms of psychotherapy. Having said this, most individuals (including children) can benefit from CBT. Individuals who don’t like talking at all are likely to drop out of any therapy, including CBT.

With undergraduate and graduate degrees from the University of Toronto, Rudy comes with over 20 years of clinical experience in Emergency Psychiatry at the University Health Network.

Rudy also works in his private psychotherapy practice and via the web in “skypotherapy.” A prolific author and speaker, Rudy has released “The Core of Happiness” – a book dubbed “the great Canadian novel on Happiness” – having himself faced early parental loss as well as the death of four children by age 33. Download Chapter One for free! Rudy has co-founded a software development company specializing in Computerized Cognitive Behavioral Therapy for web- and smart phone-based applications. As of 2010, Rudy has been named the National Health and Happiness Examiner for Canada. You can contact him by email via rudy@happysolutions.net.

Just when all was seemingly quiet, along came the Privacy Commissioner’s “Guidance on Covert Video Surveillance in the Private Sector” and PIPEDA case #2009-007, both released in May 2009. The Guidance document and this decision both created a stir sending insurers back to examine practices and protocols internally.

The Guidance document is premised on the concept that covert surveillance is an extremely privacy invasive form of technology and should only be considered as a last resort and in the most limited cases. The foundation for the Guidance document is not new. The comments and recommendations are founded in the principles of PIPEDA. The collection of the personal information via surveillance must be for the limited purpose for which it is conducted, there must be an evidentiary foundation for the surveillance on file and the breach of the individual’s right to privacy must be balanced against the benefit to be gained. Post-litigation surveillance is more likely to be considered to have been conducted with implied consent but should still be preceded by conflicting evidence on file. Pre-litigation surveillance must satisfy the provisions of section 7(1)(b) of PIPEDA.

What arose from decision #2009-007 and has been highlighted in the Guidance document concerns not the surveillance of the claimant but of third parties captured on the surveillance. The PIPEDA concept of “limiting collection” (Principle 4.4) tells us that we must limit both the type and amount of information to that which is necessary to fulfill the identified purposes. The Privacy Commissioner recognizes that there may be situations in which the collection of third party images is relevant to the purpose. In these cases it seems, the Commissioner would find the collection of the third party information potentially warranted. If an individual is merely in the company of the claimant, PIPEDA does not allow for the collection of their personal information without their consent. In the Guidance document the Privacy Commissioner advocates for deleting or depersonalizing the information captured of a third party “as soon as is practicable” and using blurring technology when required. The Privacy Commissioner recognizes that blurring is a costly venture.

Case Summary #2009-007 involved surveillance of an insurance claimant in a legal dispute with an auto insurer. The covert surveillance in question included images of the claimant’s sister and her daughter. At some stage either before or after litigation, the surveillance was disclosed to the claimant and the third parties learned of it. That in turn led to a complaint by the third parties against the private investigation firm. In spite of the fact the Assistant Privacy Commissioner recommended the depersonalization or blurring of images of the third parties the private investigation firm refused. It agreed to amend its policies to collect third party information that is “reasonable in the circumstances” but it refused to be limited by the requirements of consent in the exercise of their task. The Assistant Privacy Commissioner found this surveillance to be in breach of Principles 4.4, 4.4.1 and 4.3 (limiting collection and collecting without consent) since it was admitted by the private investigator that the collection was inadvertent and not relevant to the purposes. The Commissioner requested that the private investigator destroy all personal information of the woman and her daughter. The Commissioner as of yet has no power to order the destruction of the information under PIPEDA (although it has been suggested the Commissioner’s power to make orders may be forthcoming in legislative amendments). Accordingly, if the recommendations of the Privacy Commissioner are not followed, the remedy is for the matter to be escalated to the Federal Court for an order. The Privacy Commissioner did not take this matter to the Federal Court.

The position taken by the private investigator seems to me to be a reflection of where much of the industry finds itself on this issue still today. We do not really want to have to blur the images as a matter of practice. It is an administrative nightmare and far too costly. What is clear is that the Guidance document is just that, “guidance”. The blurring suggestion does not have the force of law but since its principles are founded in PIPEDA, it must be given consideration with those principles in mind each time video surveillance taken contains third party images. There are no timelines put on the industry concerning third party images, other than to deal with them “ as soon as practicable.” I understand that the private investigators as a rule are reluctant to tamper with the evidence both because of time, cost and the greater evidentiary problem it can create in litigation. As a litigator, the blurring requirement was the aspect of the Guidance document that I found most difficult to reconcile and recommend to clients because of the impact on the integrity of the evidence. I would continue to advocate for maintaining a copy of the original document in a secure location, even if blurring is to occur on copies to be disclosed, for so long as litigation is contemplated or ongoing. It seems by virtue of Case Summary #2009-007 that the Assistant Privacy Commissioner may disagree with me. Clearly in this regard, each company must be guided by the advice of its counsel.

The problems with the collection of third party information seems to arise when the fact the information is collected comes to the attention of the third party in question. That disclosure of the surveillance may be either as a result of an access request where information is then passed on by the claimant to the third party, or in litigation when it is relied upon as a relevant document. Perhaps it is that disclosure that should trigger the consideration of whether the blurring of images contained on the surveillance is appropriate or not in the circumstances. It remains to be seen whether the Privacy Commissioner would find that timing “as soon as practicable”. Following litigation, when there is no longer need for the document in an unaltered form, it seems prudent that third party images would be blurred if the surveillance is requested or that the evidence is destroyed entirely after an appropriate retention period.

Even with the passage of two years since the Guidance document was released, how insurers should deal with collection of third party personal information is not much clearer. The passage of time and more decisions rendered by the Privacy Commissioner is what is required. For now, we and the Privacy Commissioner it seems, will deal with it on a case by case basis. If the Commissioner’s failure to appeal the Case Summary 2009-007 is any indication, there may be some recognition that the request to blur images is problematic on many levels.

2. Don’t be afraid to use the phone. In my numerous assessments, I’ve found that the intake interviews and subsequent telephone discussions with claimants generally lacked the necessary depth of questioning and probing for information needed to understand the medical, vocational and non-medical barriers to recovery and return to work. The adjudicators will often be either afraid or uneasy asking the more sensitive questions.
A good initial telephone interview is multi-faceted. It provides data on which a claim decision is based as it allows the adjudicators to full picture and establishes rapport with the claimant. It enables the adjudicators to indentify non-medical issues and fill in gaps found in the file.
A thorough telephone interview is the best early means to identify those issues that are key to the claim. Emphasis should be placed on the adjudicator to complete a detailed initial telephone interview prior to the acceptance of liability. Initial Telephone Interviews should be appropriately conducted and properly documented for every new claim received (except advanced stage cancer and terminal illness conditions), prior to rendering a decision.

3. Medical Consultant referrals: Although the industry as a whole has improved, we do observe adjudicators placing the liability decision onus on the Medical Consultants, namely by the way they phrase their referral questions. While in the past, Adjudicators were specifically asking the Medical Consultants if “the claimant was totally disabled” or “how long they should be off work”, now the same questions are being asked, but in a different manner or by using different wording. Referrals are often vague without any precise questions being asked in regards to the claimant’s restrictions and limitations. The Medical Consultants can only comment on the medical information provided to them to review, in conjunction with a job description, if one has been provided. The determination of disability is a contractual one, based on many factors, of which the medical information is only one. By allowing the Medical Consultant to make the claim decision, you may be putting the file in jeopardy in the event of litigation. For example, if the Medical Consultant determines that based on the medical information in the file, that the claimant is totally disabled and the claim is ultimately declined for contractual reasons, an argument for punitive damages against the insurance company could be made. The plaintiff’s lawyer will argue that the company went against their own Medical expert, who determined that the claimant was totally disabled. Potential litigation exposure could be reduced or avoided by re-phrasing the referral questions to the Medical Consultant.

Referrals questions such as:
• « […] Is the claimant totally disabled ? »
• « How long should the claimant be off work ? »
• « Please review. »

Should be replaced by:
• « Please comment on the claimant’s current restrictions and limitations. »
• « Is the current treatment optimal considering the claimant’s current diagnosis, limitations, symptoms, etc? »
• « Please comment on (Specify the test results/exam/specialist report) received on (xx/xx/2011). Is the treatment optimal based on these tests results? What would the optimal treatment be?»

4. Written communication: Be clear, be precise… but foremost, be understood! Avoid using industry jargon. Also, when approving a claim, explain how the monthly benefit is calculated. Rarely will a letter explain a partial benefit calculation sent to the claimant… why ? Ask yourself, if you would pay your utility bill if you were told this “is the amount to pay” and without being provided calculation details?

Instead of writing this:
“Benefits have been approved effective June 15, 2011 in the monthly amount of $2,379.00. Your initial payment covering the period of June 29, 2011 through to July 31, 2011 has been issued to you under separate cover.”

Try this:
“Benefits have been approved effective June 15, 2011 in the monthly amount of $2,379.00 calculated as follow:

Pre-disability monthly salary: $3,568.32
Percentage % 66.67
Monthly benefits payable $2,379.00

A payment in the amount of $3,566.50 covering the period of June 15 through to July 31 has been issued to you under separate cover.

Calculation:

Period of June 15 – June 30: 15 days / 30 x $2,379.00 = $1,189.50
Period of July 1 – July 31: $2,379.00
Amount payable $3,568.50

5. Detailed Case Management Plan: The one thing that is emphasized over and over during my claim reviews is the proper utilization of Case management plans. Each claim file should contain a Case Management Plan that is long term and proactive in nature. These plans should be regularly updated and include not only immediate next steps, but should clearly outline a future course of action for the claim file. The plan should focus upon one or more of the following areas based on the specifics of the claim: Medical Development; Return to Work and vocational rehabilitation potential; and benefit Offset/adjustment issues. When used properly, this helps anyone looking at a claim to better understand what the claim issues are and what next steps to be should be taken. Also, this makes it easier for another adjudicator to begin working on an existing file by knowing what the thoughts and plans were of the prior adjudicator. This makes for a smoother transition of the claim file from one adjudicator to the next and avoids a total re-adjudication of the file on each and every occasion.

Entries such as
• “Received medical report from Dr. Smith, benefits extended to Nov 30, 2008. F/U CPP at that time.”.
• “Get APS in 6 months”.
• “Ask claimant to call us when he returns to work”.
Should be replaced by
• “Received medical report from Dr. Smith. Based on the recent MRI, the claimant will remain disabled for an additional 6 months. Approve benefits to Nov 30/08 and request a copy of the updated clinical notes at that time. If there is no improvement noted, begin the COD investigation 3/1/09. Based on the results of the COD investigation, follow-up on the status of the CPP application at that time.
• Obtain a copy of the updated medical notes and recent test results from Dr. Smith if no RTW indicated by April 1, 2009. Depending on the information received, consider an IME or FCE at that time.
• Contact the employer on January 1st, 2009 to confirm the claimant’s RTW date.