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OTHER PFR AGENCIES
Maine.gov > PFR Home > Insurance Regulation > UNUMProvident Multistate Examination/Settlement Agreement
PROOF OF LOSS—DISABILITY CLAIMS
Introduction: The Companies’ disability contracts require claimants to file a completed claim form when they are making a claim for benefits. This completed claim form satisfies the claimant’s initial obligation to provide proof of loss as discussed below. Thereafter, the Company and the claimant work together to expedite the identification, retrieval and review of all information necessary to validate the payment of benefits under the applicable policy. The following details the proof of loss process:
Initial Proof of Loss: As part of the claim submission process, the claimant must provide information concerning the impairing condition. This information includes:
Ongoing Proof of Loss: Once initial information is provided, the claimant has a legal obligation to cooperate with the Company’s efforts to obtain any material information needed to assess the claim on an ongoing basis.
Company’s Obligation to Verify and Validate: When a claimant submits a claim, the Company must first verify that the claimant is eligible for coverage under the applicable policy(ies). The Company also must validate the nature of the impairment and how it limits or restricts the claimant from engaging in his or her occupation. The Company’s obligation may be fulfilled by seeking additional information, which can include:
The Company is entitled to request a written authorization from the claimant in order to obtain additional medical or other information. The Company has an obligation to use such authorization to seek needed information at its own expense. The claimant is obliged to cooperate by providing information or documents in his or her possession and by otherwise participating in the claim investigation (e.g. attendance at an Independent Medical Examination.)
Communications with the Claimant: Throughout the claim administration process, the Company must alert the claimant as to any information or documents which are needed to pay benefits under the applicable policy.
Independent Medical Examinations and testing: In some instances, it may be appropriate for the Company to invoke its contractual right to request that the claimant submit to an Independent Medical Examination, which may include additional medical tests. Specific guidelines for such Examinations are set forth in Exhibit 6.
Claim Handling Decisions: After the Company has made a good faith effort to obtain all material information necessary to make an informed claim decision, the information is analyzed and weighed in a fair and balanced manner. If the Company has sufficient evidence to validate the payment of benefits under the applicable policy’s requirements, the claim will be paid.
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