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not have documentation of status notification within the 30-day time frame stipulated in this regulation.

Total Claim Population

  • #

    Claims in Sample

    • #

      Claims without final determination at 45th day

    • #

      Claims without status notification after 45th day

% Sample in violation

Results: The Company does not meet this standard.

220 77 53 13 24.5% (Outside 5% tolerance)

Standard #6 Claim files shall contain all notes and work papers pertaining to the claim in such detail that pertinent events and the dates of such events can be reconstructed. WAC 284-30-340 (Appendix VI)

The Individual Disability Benefits Guide, Section II, page 28, details the type of information required to document files. This section is explicit, and explains that all actions much be documented impartially and completely.

In reviewing the claim files, we found that files were missing pertinent documentation. The information showing how a settlement offer is calculated was not routinely added to the file until after discussions took place with the claimant. At that point, the offer meeting was documented, but how the offer was arrived at was not. Settlement offers are presented by a field representative who does not have access to the file. It is especially important to document the details of the calculation of the settlement offer in the permanent file.

Of the 77 files examined, the paperwork does document the major activities and decisions in 73 files, while settlement offer documentation was missing from four (4) files.

Total Claim Population

  • #

    Claims in Sample

    • #

      Claims files not fully documented

% Sample in violation

Results: The Company meets this standard.

220 77 4 5% (Within 5% tolerance)

Standard #7 If claim payments are made without a final determination on the claim, the company must advise the claimant of possible reimbursement in writing. WAC 284-30-350(7) (Appendix VII)

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