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Disability Claims Management

A full range of insurance disability claims management

 

CORE COMPONENTS

  • The disability claims management service offering entails the following core components:
  • Comprehensive medical evidence collection and collation;
  • Independent clinical assessment by qualified medical practitioners throughout South Africa and sub-Saharan countries;
  • Scrutiny of and recommendation based on all medical documentation by a medical practitioner qualified and experienced in life insurance disability assessment and rehabilitation (Fellow of the Institute of Medical Life Underwriters SA);
  • Scheduling, confirming and ensuring compliance of claimant attendance at the required consulting facility;
  • Medical consultancy facilities throughout South Africa and sub-Saharan countries
  • Comprehensive reporting on prognosis, prospects for rehabilitation and return to work;
  • Rehabilitation prospect and cost calculation, implementation and compliance monitoring of rehabilitation;
  • Direct one-on-one consultation, where relevant, with third party rehabilitation providers;
  • Operating claimant confidential Clinical Call Centre;
  • Direct one-on-one consultation, where relevant, with the insurer and/or re-insurer Claims Manager and/or Chief Medical Officer.

STANDARD medworx PROCESS

The following is the standard process applicable to the medworx disability management protocol:

  • Intermediary/Consultant, Underwriting Claims Department, or Employer will provide medworx with Benefits & Policy Rules relevant to the applicant policy;
  • Intermediary/Consultant, Underwriting Claims Department, or Employer will provide medworx with a completed Disability Assessment Request Form;
  • medworx will conduct a Preliminary Scrutiny of 3.2.1 and 3.2.2 above to ensure validity of claim and pass a written opinion on this to the claims manager / underwriter;
  • If the Claim is merited and the medical evidence is deemed satisfactory & compliant with the information required by the claims manager/underwriter, the claim is forwarded to the underwriter with a report by the medworx medical professional substantiating the validity of the Claim.
  • If the Claim is merited and the medical evidence is insufficient or inadequate, medworx will (with the underwriter’s authority) schedule a Medical Disability Assessment by a trained medworx Professional Consortium Clinician (available throughout Southern Africa). This evidence is scrutinized to ensure the adequacy and standard of the clinical evidence and a recommendation based on the medical evidence is made by the medworx medical professional (3.1.3 above) and forwarded to the claims manager/underwriter;
  • If the Claim is NOT merited and the medical evidence is deemed satisfactory & compliant with the information required by the claims manager/underwriter, the Final Disability Assessment Report will be forwarded in confidence to the claims administrator and/or Underwriting Claims Department.
    • Determine the need and nature for further evidence;
    • Determine the cost of the additional evidence from a suitable source (specialist, Occupational Therapist, Physiotherapist, laboratory, radiologist, etc);
    • Communicate the cost of the above to the claims administrator and comment on the value such evidence will provide with regard to the claim (e.g. the cost of additional information/evidence relative to the cost of claim settlement; or whether the additional information/evidence is likely to be insufficiently robust and therefore not economically feasible).
  • medworx will only proceed with the claims process if the claims administrator agrees in writing to payment of any additional cost.
  • In the event that further evidence is required, this will be co-ordinated by medworx.
  • Once sufficient evidence in terms of the Rules of the Policy/Scheme has been collected and is considered to stand up to scrutiny in a Court of Law, the Final Disability Assessment Report will be forwarded in confidence to the claims administrator and/or Underwriting Claims Department.

 

DISABILITY REPORT COMPONENTS

  • The Final Disability Assessment Report will comprise:
    • medical, psycho-social, work capability evidence (any, alternate and own occupation) pertinent to the claim;
    •  presence of co-incidental co-morbidity and whether this has any impact on the disability and its prognosis;
    • comment (if applicable) on the veracity/substantiation of evidence;
    •  opinion/prognosis of the claimant’s overall condition and in relation to the disability claimed for;
    •  opinion on activities of daily living;
    • opinion on the ability or inability (work impairment) of the claimant to conduct his/her own and/or any occupation;
    •  comment on prospects for rehabilitation and return to own or any occupation (see Vocational Rehabilitation Benefit Below);
    •   feasibility of rehabilitation in current role or alternative occupation.
  •  Unless otherwise requested in writing by the underwriter, the Final Disability Report submitted to the claims administrator and/or underwriter will NOT:
    • pass opinion on whether a claim should be admitted or declined;
    •  whether or not compensation should be awarded.

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