Our inspectors offer three distinct services seen above:
TRIAGE Health Claims Visiting Service
The TRIAGE Health Claims Visiting service has now been in operation since December 1999 and during that time we have seen a substantial increase in business. Our main objectives are to:
• provide Health Claims Visitors with a nursing or occupational therapy background to help Claims Managers with the assessment of continuing claims to ensure that they remain valid; and
• identify those claimants whose motivation and circumstances enhance the probability of returning to employment given proactive rehabilitation and case management.
Our specialist Health Claims Visitors have a variety of specific skills and are experienced in dealing with:
• the medical, psychiatric and technical aspects of disability claims
• rehabilitation, occupational health issues, work place assessments, careers counselling and employer liaison.
Our Health Claims Visitors effective assessment and report will cover the following points:
• Observation of the claimant in their living environment;
• Discussion and assessment of the claimant’s abilities and limitations.;
• Identification of any inconsistencies in the claim or any hidden agendas or secondary gain factors;
• Noting any abnormal illness behaviour or psychological influences.
Claims assessment relies on what the claimant can do rather than what they (or others) say they cannot do, or what the claimant chooses not to do. Assessments are independent, objective and holistic. The claimant’s mental state will also be assessed as underlying psychological problems can have a significant influence on physical functioning. Our Health Claims Visitors will take account of previous qualifications, skills and interests in making the assessment.
Visits can either be announced or unannounced depending on the insurer’s preference. The Health Claims Visitor will arrange a mutually convenient date and time for the visit by telephone or letter. If we encounter any difficulties we will inform you as soon as possible.
One of the Health Claims Visitor's main objectives is to try and establish the true physical functioning levels and psychological status. It is particularly important that these are carried out in an unobtrusive and non-invasive way. This is done by observation and discreetly encouraging the claimant to carry out various simple tasks which will involve mobilising, bending, lifting, sitting, manual dexterity, the use of relevant questionnaires if appropriate, assessing cognitive functioning and the use of non-direct and direct questioning.
A number of our clients now ask for a TRIAGE claim form visit for self-reported disabilities such as anxiety state, depression, chronic fatigue and where the disability is said to be stress related.
As part of our overall service the nurse visitor will make one further contact with the claimant by telephone at an agreed time after the visit to review the claimant’s progress and will provide an additional brief report. There is no additional charge for the single extra contact by telephone. Further follow-ups can be arranged for an additional fee.
Group Scheme Business – Employer Visits
For Group Scheme business our Health Claims Visitors will also visit a claimant’s employer to discuss the opportunities for rehabilitation to the claimants original occupation or to an alternative occupation. Our Health Claims Visitor will ensure that the employer is aware of his or her responsibilities under the Disability Discrimination Act and of the State help that is available to retain a disabled person in employment.
Personal Capability Assessment
Many insurers base Income Protection and Permanent and Total Disability Critical Illness claims on Activities of Daily Living (ADL’s) or Activities of Daily Work ADW’s).
Our Health Claims Visitors are able to carry out an assessment to determine whether the criteria for benefit is fulfilled.
In the event that the Health Claims Visitor is unable to fully establish the extent of disability or where there are suspicions, further investigations will be recommended e.g. an IME, functional capacity testing or covert surveillance.