EXHIBIT 1
CLAIM REASSESSMENT PROCESS, UNIT STRUCTURE AND OPERATING PROCEDURES
Exhibit 1 is responsive to Paragraph B.2.a of the Regulatory
Settlement Agreement
I. Purpose
In accordance with the Regulatory Settlement Agreements (the
“Agreements”) entered into by Unum Life Insurance Company of America, The Paul
Revere Life Insurance Company, Provident Life and Accident Insurance Company,
Provident Life and Casualty Insurance Company, the Lead Regulators and
Participating Regulators, and the U.S. Department of Labor, and in accordance
with a substantially identical regulatory settlement agreements entered into by
First Unum Life Insurance Company, the New York Superintendent of
Insurance, the Lead Regulators and the
United States Department of Labor, a Claim Reassessment Process (the “Reassessment Process”) and a Claim
Reassessment Unit (the “CRU”) have been established. This document describes the Reassessment Process and the
structure and operating procedures of the CRU.
Unum Life Insurance Company of America, The Paul Revere Life Insurance
Company, Provident Life and Accident Insurance Company, First Unum Life
Insurance Company and Provident Life and Casualty Insurance Company shall be
referred to herein as “the Companies”.
II. Reassessment
Process
a. Specified Claimant: “Specified
Claimant” is defined in Paragraph B.2.b. of the Agreements.
b. Initial
Notice to Specified Claimants: Beginning earlier and ending no later than the fifteenth business
day following the Implementation
Date under the Agreements , the Companies will mail an Initial Notice to
Specified Claimants advising them that they may have their claim reassessed by
the CRU. The Initial Notice will be dated no earlier than the date that it is posted in the mail. Specified Claimants electing to participate
must respond to the Initial Notice within 60 days of the date of the Initial
Notice. The form of notices are set forth in Attachment A-1 and Attachment A-2
to this Exhibit. With respect to any Specified
Claimants whose mailed notice is returned as undeliverable, the Company shall
use reasonable efforts to obtain a more recent address through appropriate
means to locate individuals including additional letter-forwarding services
offered by the United States Postal Service, the Internal Revenue Service and
Social Security Administration and the date for response shall be adjusted
accordingly..
c. Acknowledgement:
Specified Claimants who respond that they would like their claim reassessed
(a “Confirmed Claimant”) will have their response acknowledged in writing
within 30 days of receipt of the response.
d. Reassessment
Information Form: Prior to the date
when the CRU will begin reassessing a Confirmed Claimant’s claim, the Confirmed
Claimant will be sent a letter stating the approximate time for review of his
or her claim. The Confirmed Claimant
will also receive a Reassessment Information Form requesting information to
support the reassessment of the claim in question. All Reassessment Information Forms must be returned within 60 days
of the date of cover letter to the Reassessment Information Form, which will
also be a date that is no earlier than the date the letter is posted in the
mail, in order to be considered by the CRU, unless the Confirmed Claimant
requests in writing an extension and explains why such an extension is needed.
The cover letter is set forth as Attachment B to this Exhibit and the
Reassessment Information Form is set forth in Attachment C to this Exhibit.
e. Acknowledgement: Confirmed Claimants who return their
Reassessment Information Forms will be sent an acknowledgement of the receipt
of the completed form within 30 days of its receipt or a request for specific
information needed to complete the form in order for the CRU to review the
claim.
f.
Requesting Claimants: “Requesting Claimants” means (i) those
claimants whose claims were denied or
terminated prior to January 1, 2000 and no earlier than January 1, 1997 and the
claimant would otherwise be included within the definition of “Specified
Claimant” except for the application of the January 1, 2000 date, and (ii)
those claimants whose claims were denied or terminated on or after January 1,
1997 and prior to the Implementation Date who dispute the Companies’
characterization on any rational basis that such denial or termination falls
into any of the reasons outlined in (i) – (iv) of the definition of “Specified
Claimant” and in both cases are entitled under Paragraph B.2.b. of the
Agreements to request to have their claim reassessed. Claimants who come within the definition of Requesting Claimants
must make a request to the Company within 180 days following the Implementation
Date. Requesting Claimants who make a request within this time period will be
provided a procedure that is essentially identical to that described in
Paragraphs II. c. though II. e. above, and as otherwise generally described in
this Exhibit 1 for Confirmed Claimants, except that the reassessment process
for Requesting Claimants will begin after the reassessment of the Confirmed Claimants
is substantially complete. The reassessment schedule for Requesting Claimants
will begin with the oldest of the claims of the Requesting Claimants that were
denied or terminated being reassessed first.
Tracking data on Requesting Claimants will be kept separate from that of
Confirmed Claimants.
III. Claim
Reassessment Unit:
a. Structure of CRU: The CRU will operate
as a unit of the Benefit Center and will report to the most senior executive in
charge of claim operations. The CRU
will be staffed with personnel who have experience with group and/or individual
long term disability claims handling. Other staff available to the CRU will
include clinical consultants (nurses), physicians, vocational rehabilitation
specialists and attorneys. The staffing of the CRU will be based on the number
of individuals needed to review and investigate, within a two year period, all
requests for reassessment submitted by Confirmed Claimants.
b. Claim Review Schedule: The CRU will
review the claims of Confirmed Claimants based upon the date the claim was
originally denied or terminated with the oldest claims being reviewed first.
c. Standard of Review: The CRU will apply
a de novo standard of review using the claims handling procedures, including
those provided for in the Regulatory Settlement Agreement which will have been
implemented as of the date of any reassessment by the CRU.
d. Investigation and Decision Process: The
CRU will gather any appropriate information not contained in the claim file or
in information provided by the Confirmed Claimant including, but not limited
to, medical, occupational and financial information. Medical analysis will involve utilizing internal and external
resources as appropriate, including peer calls and independent medical examinations
and will adhere to established protocols.
Once a claim decision is determined, it will be reviewed by either the
Manager of the CRU or a Quality Compliance Consultant, as appropriate, and
communicated to the Confirmed Claimant.
e. Reopened
Claims: Any claim that is reopened and will require additional claim
handling will be referred to the appropriate unit of claims operations.
f. Tracking and Reporting: The CRU will electronically track
information related to the Claim Reassessment Process. The information will include, but not be
limited to:
i. Names of Specified Claimants and state of residence
ii. Date of Mailing Initial Notice to
Specified Claimants
iii. Names of Confirmed Claimants
iv. Date Acknowledgement sent to Confirmed
Claimants
v. Date Reassessment Information Form
sent
vi. Date completed Reassessment Form is
received.
vi. Beginning date for reassessment of
each Confirmed
Claimant’s claim.
vii. Decision date for each reassessment.
viii. Outcomes of reassessment decisions.
Matters listed above that involve
mailings to the claimant will be dated no earlier than the date in which they
are posted in the mail. Reports will be
provided to the Regulatory Compliance Unit and will be produced to reflect
results on a state by state basis using the residence of the claimant as the
basis of the state for which a claim is reported as well as on a group basis.
IV. Monitoring
of Claim Reassessment Process and CRU
a. The
Regulatory Compliance Unit will request that internal audits of the CRU process
and decision-making be conducted on a quarterly basis, and establish a schedule
of internal audits, including the number of reassessed files and other subjects
to be audited. These internal audits
will be conducted by the internal audit unit under guidelines approved by the
Senior Vice President of the Claims Operations. The results of those audits
will be provided to the Regulatory Compliance Unit for reporting to the
Regulatory Compliance Committee of the Parent Company’s Board of Directors, the
Lead Regulators and Senior Management of the Parent Company.
b.
Lead Regulation Review Decisions by the
CRU and its procedures are also subject to review by the Lead Regulators and the DOL
as they deem appropriate.