1. Claim Process Josée Malboeuf, Vice-President, Underwriting and Claims
RGA Life Reinsurance Company of Canada
April 23, 2009

2. Agenda Intricacies of the claims process today
Overall claim review and adjudication process
Differences in expectations between contestable and non contestable claims
Implications of fraud and any known red flags in the process

3. The claim process It all begins at the point of sale and underwriting
Be truthful
No “triaging” of info by the broker, this is the underwriters responsibility
The most complete information at this time, the less surprises at claim time

4. Overall claims review and adjudication process
Role and responsibilities of each participant in the process
The broker
Give notification of the claim
Gather some information
Deliver payment
The ceding company
Gathering the information
Adjudicating the claim in all fairness
Review the underwriting process/answers
Packaging the claim to the reinsurer
The reinsurer
Reviewing the information received
Make a recommendation to the ceding company

5. Details of the Claim review and adjudication process
Upon reception of information:
Data base check to see if premiums have been paid,
underwriting followed treaty guidelines,
other policies on this same insured
If all is in order, will review the claim documentation
Basic requirements
Claimant statement
Proof of death
Underwriting papers
Medical records (on a case by case basis)
Validation of smoker vs non smoker status
Physician Statement
“special requirements”:
Death on foreign soil
Contestable claim
Delivery of the policy details
Depends on the coverage claimed for ex: CI vs life vs DI.
Agent Statement

6. Contestable vs non contestable claims
Requirements might be different
More in-depth investigation of early claim
Any misrepresentation at time of uw?
Delivery of the policy, how was it done?
Circumstances of death, disability, CI claim
Life: accidental?
CI: definition of covered impairments. Moratory period?
DI: definition of disability (own occ/all occ). Waiting period? Exclusions?

7. Red flags
Early claim
Undue pressure from the broker and beneficiary to pay the claim
No pressure from either one of them
Foreign death claim (harder to get the whole picture ie source of document. Different language. Fraud)
Overinsurance
Mismatched information from different sources (ex: med info, lifestyle, income)
With the economic turbulence, more vigilant on both the uw and claim
Disguised suicide
For DI coverage: With loss of employment no incentive to get better and return to work as no work to return to
Self employed
Increase in loan and coverage for those loans
Recent change of occupation
Recent return to work after some time off
Older than 40 and no medical history
Recent immigrant with no medical hx in Canada
Working in area of economic trouble
New self employed
lifestyle

8. Statistics Contested claims? In 2008 In 2009
168 payment of claims were denied (2%)
95 for misrep
19 for fraud
4 for change of health at time of delivery
Others include suicide
In 2009
43 payment of claims were denied (1.44%)
28 for misrep
7 for fraud
3 for change of health at time of delivery