Standard #4 Denial of a claim on the basis of a specific policy provision, condition or exclusion must be given to the claimant in writing and the file must contain a copy of the denial notification. Denials for any other reason must be noted in the file. WAC 284-30-380(1) and (2) and WAC 284-30-330(13)
The Individual Disability Benefits Guide, Section II, page 13, describes the procedure to be used when a claim is denied for any reason. This section states that a formal notice must be given to the Claimant showing the actual reason for the denial, and must include specific appeal language.
Of the 77 files examined, seven (7) contained denied benefits. Of these, seven (7) files contained written notice showing the specific reason for denial and included appeal language. Copies of all letters were included in the files.
Total Claim Population
# Claims in Sample
# Claims without denial letters
% Sample in violation
Results: The Company meets this standard.
Standard #5 When a claim determination cannot be made within 15 working days of receipt of completed proof of loss, notification must be given to the claimant within the 15 day time limit, and each 30 days thereafter. Notification must contain the reason for the delay in the investigation. WAC 284-30-380(3) (Appendix V)
The Individual Disability Benefits Guide does not contain specific
procedures to meet this standard. The Company provided copies of pages from their on- line, state specific compliance manual that includes correct Washington requirements.
Subsequent Event: In 1997, the Company created a booklet titled "Service Standards" that contains written standards for claim handling. One standard states "100% of all claimants shall received written updates on the status of their claim every three weeks before acceptance/denial."
Seventy-seven (77) claim files were examined to determine if UNUM consistently communicates status to the claimant during the adjudication process. Twenty-four (24) files were found to have a final determination prior to the 45th day after receipt of the completed proof of loss. These were eliminated from the sample.
Of the remaining 53 files, 40 contained evidence that consistent status notification was communicated to the claimant at least every 30 days. The remaining 13 claim files did