How do I get started using AI in Disability Management?

 

“Ai won’t replace people… People who use AI will replace people who don’t.”  [* IBM, “Augmented work for an automated, AI-driven world”, https://www.ibm.com/thought-leadership/institute-business-value/en-us/report/augmented-workforce  accessed Oct 5, 2023]

IBM’s assessment applies to Disability Management professionals, Rehabilitation Consultants and Personal Injury Advisors as well as clinicians, administrators, and even CEOs; those who use artificial intelligence (AI) will replace those who don’t. 

When that realization sinks in, students and participants in my workers’ compensation courses and disability management seminars often ask, “How do I start using AI?” 

Here’s what I tell them.

Step 1:  Get access to an AI chat application.

While ChatGPT is the highest profile, other popular AI chat applications like Bard, Bing’s Chat and Perplexity are available for free access in most countries (or through VPN access) subject to registration.  Subscription-based and more specialized AI applications are also available.  If your organization already subscribes to one, you may want to get started with that.

Step 2:  Create a prompt.

Chatbots respond to you.  Unlike an internet search engine, AI chat applications apply Large Language Models to what you “prompt” (the question you write or speak as an input to initiate a chat session.  One person described their first experiences with AI chats this way: “It’s like texting a detailed question to a really knowledgeable expert and getting a really complete response… but with no time lag.”

Step 3:  Interact with the application.

In an internet query, you typically ask one question then investigate by following supplied links from the response.  With AI, you can carry on a conversation; most chat applications allow you multiple (five to thirty or so) follow-up prompts, questions, or comments to which the AI chat will respond  Subsequent prompts may ask for more detail or a justification of a particular response.  You can probe, disagree, or ask for a response to be put another way.  The AI chat applications are pretty good at following the chain of conversation without restatement information already appearing in the session.

Step 4:  Review responses critically and with caution

If you are already knowledgeable about something, start with a prompt that will allow you to evaluate the responses.  AI chat applications are not authorities; they just present information in a way that sounds definitive.  In their present state of development, they make errors, hallucinate, and miss key points while emphasizing sometimes trivial matters.  What you bring to the interaction is your knowledge and judgement.  The experience of detecting and exploring errors, omissions, and overstatements will help you evaluate responses when you are not expert.

Step 5:  Verify

Most chat applications will now provide sources to support their responses either directly or if prompted.  This is important for any work you do at least at this stage in AI development. Check the references provided very carefully.  Read the papers cited to see if they actually support the statements made in the AI response. 

Practice with AI applications will help you develop your prompts to be more effective.  Here are some examples of how AI can inform and assist disability management professionals, stakeholder and advocates in their practice.

Use AI to understand appeal case decisions.

The Appeal Commission for Alberta Workers’ Compensation publishes “Significant Decisions”  on commonly appealed issues in workers’ compensation [see https://www.appealscommission.ab.ca/resources/significant-decisions] .  The selected cases are particularly clear in their organization, analysis and application of principles.  The decisions are listed by topic but not summarized or annotated.  For example, the Appeal Commission’s website lists two decisions by number under the heading “Claim Acceptance” [see Decision No. 2014-1090 , Decision No. 2014-0657].

In this example, I took the text of the two listed decisions and uploaded them to ChatGPT with the following result: 

Prompt: 

Based on the two exhibits, prepare a short summary of about 250 words for each case then provide several paragraphs outlining the principles, analysis and approach that advocates can use to inform their submissions on the acceptance of workers' compensation claims.

ChatGPT response:

Case Summary 1: Left Shoulder Labral Tear

 

In this case, a worker filed a compensation claim for a left shoulder labral tear. After examination, the first medical consultant indicated that the worker's job duties, which included frequent work in an "impingement position," likely contributed to the injury. The third orthopaedic surgeon, however, deemed the examination invalid and could not correlate the symptoms with the described injury mechanisms. The Appeals Commission ultimately sided with the first medical consultant, citing his detailed review of the worker's job demands and physical analyses, which the third orthopaedic surgeon failed to do. They also noted that the third surgeon's opinion lacked a clear rationale.

 

The Commission emphasized the absence of evidence supporting an alternate cause for the diagnosed labral tear, ruling out other potential factors. Consequently, the worker's left shoulder labral tear was deemed compensable due to the consistent medical evidence and job-related factors.

 

Case Summary 2: Left Medial Epicondylitis

 

The worker in this case was diagnosed with left medial epicondylitis. Although medical evidence confirmed the condition, it did not sufficiently establish a causal relationship with the employment hazard. The medical consultant suggested that the worker's significant exposure to force, repetition, and abnormal postures in forearm-related activities could reasonably relate to his job activities. However, the Commission found this insufficient to establish causation, as the consultant also noted that the worker reported elbow symptoms after ceasing work.

 

Additionally, the third orthopedic surgeon's examination did not support a causal connection between the worker's duties and the medial epicondylitis. The Commission emphasized that absence of evidence for an alternate cause did not automatically establish a causal link. Therefore, the claim for left medial epicondylitis was not accepted.

Principles, Analysis, and Approach for Advocates

Detailed Job Analysis: Advocates should emphasize the importance of conducting a comprehensive review of job demands and physical analyses when assessing the causal relationship between a worker's duties and their injury.

 

Clear Rationale for Opinions: Medical consultants and experts should provide a clear and detailed rationale for their opinions, ensuring that they explain the basis for their conclusions.

 

Consideration of Timing: Advocates should be aware of the temporal relationship between the reported injury and the cessation of work. This can be a critical factor in establishing causation.

 

Evaluation of Alternate Causes: While absence of evidence for an alternate cause is relevant, it alone is not sufficient to establish a causal link. Advocates should focus on gathering evidence that directly links the injury to the employment hazard.

 

Specialized Expertise: Advocates should consider the qualifications and expertise of medical consultants, especially in comparison to other examining professionals, to determine the weight given to their opinions.

 

These principles, rooted in the Appeals Commission's decisions, can guide advocates in constructing strong submissions for workers' compensation claims, ensuring they are well-supported and likely to be accepted.

 

Note that the result is highly dependent on the prompt and the AI model used.  Even replicating the above example in the same AI application will likely result in a similar but not identical response.  Changing or omitting the word count will also change the detail in the response.  If you have a decision letter on a similar claim, you can test if the principles identified in the first response are properly applied in a subsequent case.

 

Develop a job modifications and adaptations to accommodate a return-to-work  objective

In the following example, the prompt includes the instruction to assume a particular role in developing a GRTW plan.  This is a hypothetical example and for confidentiality and privacy reasons, actual names and circumstances should be avoided as you experiment with AI.

In this example, note that the prompt prescribes a point of view, an assumption of a professional position.  Note also the details contained in the prompt.

Prompt:

Assume you are a vocational rehabilitation consultant assisting a 40-year-old bank employee return to work. The employee was pursuing a hobby involving woodworking. Having removed the guard on the table saw to make a close cut, the employee amputated the ring and middle fingers on both hands below the medial pharyngeal joint. The employee is recovering well enough (after three months away) to return to work. The job duties involve a lot of sedentary work with extensive keyboarding using a standard desktop computer, keyboard, and mouse. Phone calls are made and received through a standard desktop phone with a headset. The employee has full use of thumbs, third and little finger on both hands. What modifications, devices, and adaptations to the workstation would you recommend to accommodate this employee's

ChatGPT Response:

Given the employee's condition, I would recommend the following modifications and accommodations:

 

Ergonomic Workspace: Ensure that the workstation is ergonomically designed to reduce strain on the remaining fingers and thumbs. This includes proper chair height, monitor placement, and keyboard/mouse positioning.

 

Specialized Keyboard and Mouse: Consider providing a keyboard and mouse designed for individuals with limited dexterity. There are options available with larger keys or alternative input methods like touchpads.

 

Voice Recognition Software: Implement voice recognition software to reduce reliance on extensive keyboarding. This would allow the employee to dictate text and commands.

 

Keyboard Shortcuts and Macros: Set up customized keyboard shortcuts and macros to streamline tasks and minimize the need for complex typing.

 

Adjustable Desk: Provide a desk with adjustable height to accommodate any specific needs related to the employee's comfort and posture.

 

Phone with Speaker Functionality: Use a desktop phone with speaker functionality to allow the employee to use it without needing to hold the receiver.

 

Headset with One-Sided Earpiece: Opt for a headset with a one-sided earpiece to allow the employee to use the phone while still having a free hand for typing.

 

Document Holder: Provide a document holder to keep necessary documents at eye level and reduce strain when referencing them while typing.

 

Wrist Rests and Palm Supports: Include wrist rests and palm supports to provide additional comfort and stability during keyboarding tasks.

 

Monitor Mounts: Use adjustable monitor mounts to position screens at an optimal viewing angle for the employee.

 

Training and Support: Offer training on any new assistive technologies or workstation adaptations to ensure the employee is comfortable and proficient in their use.

 

Regular Check-Ins: Schedule regular follow-ups to assess the effectiveness of the accommodations and make any necessary adjustments.

 

Remember to consult with the employee throughout this process to understand their specific needs and preferences. Additionally, consider involving an occupational therapist to provide specialized guidance if needed.

 

This is a detailed outline but a bit short on details.  Follow-up questions can ask for additional information.  You could, for example, expand on the alternative keyboards items.  In my follow up, the idea of a hand-held keyboard about the size of a smartphone allowing for typing with the thumbs similar to texting was suggested. 

 

Draft a return-to-work plan

For this example, I gave the employee in the hypothetical case a name and relationships and asked the AI chat to prepare a return-to-work plan with the following prompt. 

Prompt:

Assume the employee, Arlene W., is cleared to gradually return to work in two weeks.  The employer has agreed to the points above.  Develop a formal return-to-work plan outlining what happens each week for up to 8 weeks with the employee back at full duties at the end of the plan.  The plan will be overseen by the employee’s supervisor, Jay Q., and the RTW coordinator, Peter L.  Any adjustments to the plan will be agreed upon by all three parties.  The plan should be formatted as an agreement using the calendar weeks and dates that would apply.

I’ve posted the ChatGPT response as an image and a PDF (some formatting added). 

The product is well organized but sparse in detail.  That is understandable given the brevity of the prompt.  Adding more details could result in a more detailed. In practice, the output could be used as a starting point.

As an additional exercise, paste an anonymized version of on of our own RTW plans into an AI chat with a prompt as follows:  Review the following return to work plan commenting on its completeness, pointing out any deficiencies and make recommendations for amendments, deletions, or other changes. 

This exercise is framed as a self-check, something you might do in your own practice, but that is too narrow a perspective.  You can be certain that many of those receiving your RTW plan proposal will run a similar exercise as part of their own due diligence before signing off on your proposal.

Recommendations

I’ve stressed the need to be knowledgeable about AI but to be cautious in its implementation.  The only way you can develop your understanding of AI is by using it! 

And, keep in mind these  four recommendations, one hint, and a final caution:

•  Start interacting with AI tools now to become familiar with their evolving utility.
• Be sure to adhere to all ethical, confidential, privacy and academic integrity guidelines.
•  Practice being critical of AI responses. (Hint:  Practice by creating AI prompts that will generate responses in your area of expertise and examine the response for errors, omissions, and misinterpretations or outdated perspectives).
• Verify information before using AI information (AI is NOT an authority even if its responses are framed as authoritative assertions).

 

Remember, AI chat applications are known to hallucinate, make up quotes, and attribute them to articles that may not exist.  If you catch AI making an error or flawed reasoning, follow up with the AI application.  It is very common for AI chatbots to apologize, acknowledge their errors, and amend their responses—but only if you pursue the point. 

AI is here to stay, being integrated into existing technologies,  and continuing to evolve.  Use it to make a difference in your profession.

AI and Workers' Comp - Summary of ARPA presentation

The recent Australian Association of Rehabilitation Providers (ARPA) Roundtable meeting in Perth provided an opportunity to speak on how AI is and will impact workers’ compensation.  

In my presentation, I noted that AI has been applied in research and proprietary settings for years but that the advent of low or no-barrier access to Large Language Models such as ChatGPT, Bard, Bing’s chat, Perplexity,  and others have quickened the pace of AI application and adoption. 

AI will not change the functions of any disability insurance or workers’ compensation systems.  Using Henry Mintzberg’s approach, I illustrated how AI can be applied to functions in the technostructure, support, and strategic apex of organizations, as well as through the operating core.  The impact at the interface between the organization and those it serves (stakeholders, injured workers, employers, advocates, etc.) is dynamic and bi-directional.  AI enables organizational functions and changes how others outside the structure use, analyze and react to information and decisions.    

AON, one of the world’s largest reinsurers, [see https://insights-north-america.aon.com/total-cost-of-risk/how-artificial-intelligence-is-changing-workers-compensation ]  and  Clara Analytics [see https://claraanalytics.com/blog/six-ways-to-reduce-workers-comp-costs-using-ai/ ].have reported current application of AI in the insurance and workers’ compensation sector.  Applications that include:

• Analyzing workers’ compensation wealth of structured and unstructured data
• Sorting out the impact of events like COVID-19
• Loss control benefits for employers
• Detect anomalies in procedures and drug costs
• Evaluate, decide, and pay 60-70% of straightforward claims
• Identifying high risk and complex cases early and direct to specialist staff
• Enable early intervention.

I demonstrated how a complex 43-page appeal-level decision could be uploaded to a chatbot with a prompt to produce a 500 word, plain-language summary along with the strengths and weaknesses of the decision.  The near instantaneous output matched the quality of my own summary and analysis that took more than half a day to prepare. 

In another example, I showed how AI had been trained to analyze and code a few thousand workers’ compensation cases, apply that learning to a dataset of 1.2 million cases and produce actionable analytics for prevention of injuries in specific sectors. 

A recent IBM report [see https://www.ibm.com/thought-leadership/institute-business-value/en-us/report/augmented-workforce noted “AI will not replace people – but people who use AI will replace people who don’t.”  Putting a finer point on this, I noted:

• AI won’t replace clinicians but clinicians who use AI will replace clinicians who don’t.
• AI won’t replace rehabilitation and return to work specialists but rehabilitation specialists  who use AI will replace rehab professionals who don’t.
• AI won’t replace CEOs but CEOs who use AI will replace CEOs who don’t.

My final points reiterated that AI is here, it is not going away, and it is going to increase in power.  Ignoring and fearing it are not really options.  Understanding AI, how to use it, and its limitations is essential.

Workers’ compensation or disability insurance are not islands.  As clients, injured workers, regulators, advocates, and stakeholders adopt AI and experience how sectors and services using this technology to improve quality and timeliness, they will demand improvements in these sectors as well.   Even if you are meeting or exceeding your service, timeliness, and quality standards now, by the measure of the AI-enabled world, you are falling behind.  Your reputation and social capital will suffer as a result. 

The discussion following the presentation included insightful questions and observations.  One key insight was the importance of crafting the prompts used with large language models.  The richness and accuracy of the prompts will be somewhat determinant of the product of an AI interaction. 

Also covered in the discussion was the importance of the professionalism, knowledge, and experience users bring to AI interactions.  At this point in AI implementation, those human insights and judgements are essential.  In one of the presentation examples, the AI chatbot was prompted to read a case study from the ARPA website and develop a specific multi-faceted rehabilitation plan for a complex case.  The output accurately reflected what the current body of disability management and rehabilitation management knowledge would ideally recommend.  The realities and constraints of implementing the plan, adapting the ideal to the specific context, and “doing” the work required professional human judgement to achiever the real-world objective of a safe, durable return-to-work outcome.

Another comment built on the cautions raised in the presentation regarding privacy, confidentiality, and regulatory issues. While all the examples used in my presentation were from publicly available sources, professional judgement and rigorous compliance with regulatory and professional standards will complicate implementation of AI in organizations.

The call to action for this presentation was engagement.  It is time to educate subject matter experts in all functional areas of your organization about AI and begin the process of improving and safeguarding functions across the organization. 

AI will improve workers’ compensation, disability management, personal injury insurance, and prevention. Developing your AI strategy is not just something to put on your to do list, it is a current imperative.

The Disability Insurance “trust gap” Part 2: Actions

 [This is the second part of  a discussion on the Disability Insurance “trust gap”.  It is based on notes and discussions points for sessions in a 4th year Disability Management course on Workplace Insurance and Benefits.  Part 1 explored the reasons for the lack of trust in disability insurance.  Part 2 provides three general suggestions for organization and five practice priorities individual case managers and disability management professionals can use to narrow the trust gap they face in their day-to-day work. ]

In the last post I highlighted the trust gap in the insurance sector and some of its causes in the disability insurance sector.  That sector includes workers’ compensation, group Long Term Disability (LTD), transport accident compensation and rehabilitation among others. This post focuses on what individual case managers, vocational rehabilitation consultants, return-to-work coordinators, and other disability management professionals can to do narrow that gap.  The goal of doing so is to achieve better outcomes for the disabled individuals we serve. 

Minding and mending the insurance trust gap

That trust gap doesn’t make your job as a case manager working in any disability insurance system any easier. Coupled with the complexities of systems, workload demands, and resource issues all knowledge workers face, case managers you must find a way meet the expectations of your own organization and the needs of those you are trying to serve. You may get a lot of advice on how best to do that.  Despite your efforts and the best intentions of insurers, that gap is not going to magically disappear. 

For Organizations:

Ultimately, every disability insurance insurer needs a strategy to narrow the insurance trust gap.  Unfortunately, few organizations bother to measure trust at all. 

Every organization should measure the level of trust stakeholders, claimants, and others have in their organization.  This is particularly important among those seeking benefits.  It is possible for someone who has an accepted claim to still assess their level of trust as low.  It is also likely that those with denied claims will have lower trust, but it is also possible for a denied applicant for benefits to have trust in the processes and reasons for the denial.

It is particularly important to identify and track applications that are driven by other insurers.  It is possible that the efforts of other insurers to leave no other avenue of coverage unexplored may be detrimental to your levels of trust and overall reputation.  Understanding this dynamic is critical to anyt strategy for narrowing the trust gap. 

Compare your organization to others.  This may mean agreeing with competitors, parallel organizations, or industry associations to measure trust in similar ways and with similar regularity.  We know the financial services has a trust deficit;  pinpointing your organization’s particular trust status is essential to developing and implementing a strategy to improve it. 

Narrowing the Disability Insurance “Trust Gap”  for DM professional, Case Managers

Knowing that gap exists means you can do something about it.  How you interact with those you serve can narrow that gap and improve both service and outcomes.  Here are five things you can do every day.  This guidance comes through my interactions with injured workers and disabled clients over the last four decades.  Focusing on these priorities won’t eliminate the trust gap but can help you narrow it on a case-by-case basis. 

Attend

Believe

Communicate Clearly, Concisely

Act with Dispatch, a sense of Urgency

Develop genuine Empathy

Follow through

I’ll expand on each of these ideas but realize these are independent of any corporate initiative.  These priorities are within the power of every case manager, vocational rehab consultant and DM professional in the disability insurance field. 

Attend. 

Attending means more than just showing up to a client meeting, passively listening to them on the phone or skimming the latest medical report.  Yes, your job is complex but just about every job today is complex. The circumstances giving rise to injuries are almost always complicated. 

What injured and disabled clients want is more than a series of random contacts repeatedly asking to be told the same story or continually explain the details that gave rise to the injury.  It is not only frustrating, but it can also be harmful. It may be easier for a new case manager taking over a case to ask the beneficiary to re-tell their story, but this is often just a shortcut to avoid reading the detailed information already on file.

Some insurance organizations have increased caseloads of case managers or transitioned from early and direct service by specialist professionals  to highly systematized, volume-focused, script-driven, front-end generalist  at distant call centers.  Reaching and maintaining contact with a knowledgeable specialist case manager or DM professional is often difficult.  Where part of a segmentation strategy to stream cases to a specialist professional, the upside benefits for the client may be positive.  Unfortunately, these models are sometimes introduced as corporately necessary to address cost or staffing needs and may come at a significant cost to the injured individual seeking help.  Continuity of contact over longer duration disability cases can reduce gaps in understanding and build trust.

Actively listen to your clients.  Wherever possible, reduce handoffs to others.  It you must hand off to someone else, be sure to reflect the client’s situation and concerns fully, preferably personally.  When with a client, that person should be the only person that matters (phones and email alerts should not distract from your attention). 

 

Believe.  

The clients you encounter are overwhelmingly sincere.  Believe them. 

Start with a mindset that people seeking benefits from a social or personal injury insurance plan are sincere and not trying to “rip off” the system.

The incidence of claims fraud across all property and casualty insurance lines in the Americas is estimated at about 1.38%.  [see Reinsurance Group of America, RGA 2017 Global Claims Fraud Survey available at https://www.rgare.com/docs/default-source/knowledge-center-articles/rga-2017-global-claims-fraud-survey-white-paper---final.pdf ]. 

Personal injury insurance and disability plans are not rife with fraud.  A favorite target of the rampant-disability-benefit-fraud myth is the US Social Security Disability Insurance system (SSDI).  Despite spectacular rhetoric about fraud, repeated internal and independent reviews have shown “the level of fraud in the disability program is  less than one percent…”  [see Statement of Carolyn Colvin, Acting Commissioner, Social Security Administration, Hearing Before the Subcommittee on Social Security  of the  Committee on Ways and Means U.S. House of Representative  JANUARY 16, 2014, Serial No. 113-SS09].   

Adjudicating and administering personal insurance cases is not easy. It requires expertise, judicious weighing of evidence and experience and adherence to complex law, policy, jurisprudence, and procedure.  Asking for information is diligence; repeated requests for previously provided information infers disbelief.

Consider the actual necessity of what you are asking and how your request may be received.  Even if your requests are procedurally required, the client’s reaction to yet another request for more medical evidence or medical examinations may be quite different. Your request for more (or, worse, already provided) information may communicate something between skepticism and outright an outright accusation of malingering.  Not a great way to build trust.

Start from a position of belief.  If circumstances or evidence on a particular case lead you away from that position, of course you must act accordingly; know, however, that such cases are rare. 

Communicate clearly, concisely.

We all have insurance policies of one sort of another, but few of us have read the fine print… or, having tried, are often left confused by the nuances of restrictions, exceptions, and exclusions common in almost all insurance plans.

The technical nature of personal injury insurance creates ambiguities and information asymmetries. For someone with a new disabling condition, injury or disease, the whole insurance experience is new and layered on the pain, suffering, and fear that typically come with disability, For the case manager, every new application for benefits is another of many in a very technical, policy and procedure driven system.

The very nature of insurance—the transference of specified risk of loss from the policyholder to the insurer— makes these complexities inevitable. What is not inevitable is the confusion from the way policies and decisions are communicated. It is easy to rely on the direct wording of the law or policy; it is much harder to communicate clearly without excessive reliance on legalese.

Strive for clarity in all your communications—verbal and written. Canned paragraphs and templates are necessarily vague. Be certain your communications apply exactly to your purpose.  If a standard letter does not work well, modify or abandon it in favour of something that better communicates your purpose, decision or needs.

Work with Dispatch.

“The waiting is killing me!” “What’s taking so long?” I’ve heard these exact words countless times. In an age when you can get an insurance quote with a click or keystroke, it is more than ironic that getting a decision on a benefit request can routinely take three to six weeks.

According to one source,

“…these [are the] ideal response times in the insurance industry:

Emails: within an hour

Chat: 5 minutes or less

Live chat: less than a minute

Phone calls: less than 30 seconds”

 

[See The importance of response times in the Insurance Sector (2023 Guide) - timetoreply available at https://timetoreply.com/blog/the-importance-of-response-times-in-the-insurance-sector/ ]

 

There are legitimate reasons for delays in all disability insurance administration; medical and incident reports are not filed on time, critical staff are on vacation or in training, medical diagnostics are hard to access.  The automated mantra of “We are experiencing higher than expected call volumes” is often used to hide staffing issues, system deficiencies, and intentional but undeclared decisions to simply live with delays and subsequent frustrations as the status quo.

Transparency of standards and constant public updating of performance may increase accountability and reduce wait times for decisions and payments.  Few organizations publish this sort of data on a routine and timely basis.

Recently, a disabled employee recovering from a surgery applied for benefits form her private insurer.  After weeks of delay, she received an email request for additional information, which she provided the same day only to receive a response that the adjuster was going away on vacation and would make a decision upon her return. Don’t do that. 

Regardless of the system constraints, you have the power to do your job.  If there is something that needs to be done, do it!  Do it now! 

Empathize

You know authentic empathy when you experience it.  An empathetic person has emotional intelligence—knowing and understanding another person’s perspective.  Fully attending to another is one thing; being able to see the world from their perspective is something else, something every case manager and DM professional should strive to do.

Develop genuine empathy.  I don’t mean sympathy and definitely not pity.  Repeating platitudes like “I hear you” or “I’m sorry” is not what I am talking about.  Empathy is deeply understanding and identifying with the context, emotions, frustrations, and aspirations of another. 

Follow through. 

If you say you will send out a decision letter today, then do so.  Remember, even a negative decision is often essential to access another benefit.  Saying you have made a decision and even telling someone is not enough in most cases.

If you work in DM, HR, or CM for an insurer, you will have to follow the rules of your own organization. Those rules are unlikely to conflict with acting to reduce the frustrations of those seeking their benefit entitlements.  Never be the reason for delay.  If delays are becoming systemic elsewhere in the process, seize the initiative to expedite or resolve the issue.  At a minimum, raise the issue with those who can fix it.

Where there are follow-up or review points in a return-to-work plan, for example, make them explicit, and actively monitor those review points with direct contact with the client. 

Final thoughts

The insurance “trust gap” will be a continuing factor in your work.  The best a professional Case Manager, Disability Management Professional, Adjudicator or Return-to-Work Coordinator can do is to narrow that gap with each new case, each client you encounter.  Focusing on these five themes will help you do just that.   

The Disability Insurance “trust gap” Part 1: Causes

[The following notes background and discussion points from a series of sessions Disability Management undergraduates completing a 4^th year course on Workplace Insurance and Benefits.  Part 1 explores the reasons for the lack of trust in disability insurance.  Part 2 provides five practice priorities individual case managers and disability management professionals can use to narrow the trust gap they face in their day-to-day work. ]

Many of you are currently working or will go on to work  as Disability Management professionals for a workplace insurance organization.  Whether you work as a Case Manager for  workers’ compensation system, a client services representative for a transport-accident personal-injury insurance, a claims administrator for a non-occupational disability insurance plan, or a return-to-work specialist for a third-party administrator, you will face the disability insurance “trust gap”. 

You know the primary concerns of your clients; after health and care needs, “How will I support myself (and my family)?” is the priority.  

Injury, illness, and disability have significant costs and impacts on earnings.   According to recent media report, "More than half of Canadians $200 away or less from not being able to pay all of their bills" [see CTV News, More than half of Canadians $200 away or less from not being able to pay all of their bills, at  https://www.ctvnews.ca/business/more-than-half-of-canadians-200-away-or-less-from-not-being-able-to-pay-all-of-their-bills-1.6473939 ] .  Without the financial protections of work-related, group, and non-occupational disability insurance, many would quickly reach insolvency.

Complicating interactions are pervasive attitudes and beliefs about insurance.  Whether it’s property, casualty, disability, motor vehicle or workers’ compensation, trust in insurance is low.  Skepticism and misconceptions about insurance are pervasive.  Getting beyond this starting point will always be a challenge for those who play a role in the process.  We’ll get to what you can do later.  For now, let’s examine why the disability insurance trust gap exists in the first place. 

Lack of Trust in Insurance

Most people participating in the workforce have some sense that disability insurance plans are necessary and valuable.  Most understand the basic idea of insurance; in exchange for a specified premium, the insurer assumes the financial risk associated with certain (rare but costly) defined events.  Most working people trust in the premise of disability insurance, but doubt the promise that insurers actually pay in the event of a qualifying loss. 

The trust gap is not unique to the disability insurance sector.  According to one recent report,   less than 30% of people surveyed had a positive opinion of the insurance industry, with 53% having had a negative experience. [See Peter Littlejohns,   New survey from The Geneva Association shows underinsurance is fuelled by mistrust, NS Insurance, 26 June 2019 available at https://www.nsinsurance.com/analysis/the-geneva-association-survey/  ]

This level of trust in insurance is reflective of the broader financial services sector.  The percent trust in the financial services sectors (57) has repeatedly trailed the trust index listing of fifteen industries, well behind other sectors including healthcare (67),  education (70), and technology (78). [See  2019 EDELMAN TRUST BAROMETER Global Report available at https://www.edelman.com/sites/g/files/aatuss191/files/2019-02/2019_Edelman_Trust_Barometer_Global_Report.pdf ]

The challenge of insuring disability

Disability insurance plans are big—an attribute rarely associated with trust.    “Big tobacco”, “big government”, and “big oil” are almost pejorative terms echoing generalized distrust of big institutions. 

Disability insurance plans must be big, at least big enough to accurately assess the risk of and actuarily determine the costs of covering rare, costly events.  Each of us faces the risk of a disabling injury, condition, or disease; quantifying and insuring risk is only possible when those individual risks are pooled across larger groups or population.  That ability to quantify risk and price the cost of coverage is the important “value add” of all disability insurance.

Being big does carry real challenges.   Monopolistic disability insurance providers (particularly national, jurisdictional, and state social insurance plans) lack competitive pressures of free market models.  Even where the provision of disability insurance is competitive, the market is dominated by a few, very large insurers.  The economies of scale and efficiency of being big do not eliminate the risk of market failures; without objective, transparent disclosure and oversight, the perception of distance and unresponsiveness tends to accumulate over time.

A “Big” institution of any sort is often painted as uncaring, impersonal, and even dehumanizing.  Public social insurance plans like US Social Security Disability Insurance (SSDI) and Canada Pension Plan Disability (CPP-D) are often singled out in this regard [For example, see American Progress, How Dehumanizing Administrative Burdens Harm Disabled People, 5 December 2022 available at https://www.americanprogress.org/article/how-dehumanizing-administrative-burdens-harm-disabled-people/ ]. 

As noted, disability insurance plans and programs must be large to be actuarially viable. When disability insurance plans are working as designed, funds to cover losses and administration will be there when they are needed. And that’s exactly what happens, most of the time.  Disability insurers collect a lot of money and earn a lot of return on investments, but nearly all those funds collected and gains earned are  paid out in entitlements, benefits, and administration.

Those big dollar amounts often make headlines.  Unfunded liabilities or surpluses attract public scrutiny and media criticism. Outrage at necessary increases in premiums or demands for refunds to insurance payers or increased to beneficiaries often dominate the public discourse.  Current and future beneficiaries worry about sustainability of the disability payments on which they depend.  Some of this lack of trust is rooted in a lack of understanding of disability insurance financing. 

Big public and private disability insurers tend to be financially stable over time.  Periods of excess claim costs, lower premium income, and inadequate investment revenue can result in occasional imbalances—where the funds on hand are not sufficient to meet needs.  Unfunded liability and surplus positions may persist for some time but tend to return to a balanced, sustainable level over the long run.

As an industry, property and casualty insurance is profitable for shareholders (private insurance) or financially balanced for stakeholders (public, mutual, state funds).  The disability insurance line of workers’ compensation insurance in the US, for example, has had eight years of underwriting profitability. [see Donna Glenn (chief actuary), State of the Line Report,  NCCI Insights, 18 May 2023 available at https://www.ncci.com/Articles/Pages/Insights-AIS2023-SOTL.aspx ]

Denial rates in  Disability Insurance reinforce low trust perception

Apprehensions about disability insurance are often reinforced by press reports accentuating insurer errors, social media stories amplifying egregious cases, and disability lawyers asserting disability insurers deny benefits just to maximize profits.

Behind the hyperbole and exaggeration, legitimate concerns underpin insurance apprehensions. Initial applications for disability are not always accepted.  The “acceptance” and “denial” rates vary with the disability insurance type; however, criticisms tend to be categorical, citing or implying high denial rates across all disability insurance plans (including workers’ compensation, social insurance, group and individual plans, and transportation accident disability insurance).

To be clear, the denial rates for initial applications for many disability insurance types are high.    US Social Security Disability Insurance (SSDI) applications from workers are often denied.  The final award rate for SSDI averaged just 31% (2010-2019) [See Social Security Administration,  Annual Statistical Report on the Social Security Disability Insurance Program, 2020, Chart 11 at https://www.ssa.gov/policy/docs/statcomps/di_asr/2020/ ] 

Canada Pension Plan Disability (CPP-D) has a similarly low acceptance rate with the national average was 43 percent for the 2014–15 fiscal year. [See Auditor General for Canada, Report 6—Canada Pension Plan Disability Program, 2015, available at https://www.oag-bvg.gc.ca/internet/English/parl_oag_201602_06_e_41063.html]   

Workers’ compensation denial rates are not consistently defined, similarly calculated, or widely reported.  Oregon reports its jurisdiction’s workers' compensation “Disabling Claim Denial Rate” at 10% (2022), down steadily from a high of 18.8% (1992). [See Oregon Department of Consumer and Business Services, Workers’ Compensation System, Workers’ Compensation Claims Administration table available at https://www.oregon.gov/dcbs/reports/compensation/pages/wc-claims.aspx]

WorkSafeBC reports a different but related statistic based on claims “Disallowed” as a proportion of claims reported.  At 6.3%(2022) this measure sits near the low end of a ten-year range that has been as high as 8.7%(2015). [See WorkSafeBC, 2022 Ten-year summary of consolidated financial statements — Smoothed or funding basis, available at https://www.worksafebc.com/en/resources/about-us/annual-report-statistics/2022-annual-report/2022-ten-year-summary-consolidated-financial-statements ]

Research has shown a relationship between denial rates and claims-filing behavior in workers’ compensation cases. Higher denial rates were found to be associated with lower claim-filing rates for some injuries. This was particularly true for back injuries where the relationship was statistically strong and significant.  [see Jeff Biddle, Do High Claim-Denial Rates Discourage Claiming? Evidence from Workers Compensation Insurance, The Journal of Risk and Insurance, Vol. 68, No. 4 (Dec., 2001), pp. 631-658]

Reasons for denials

Insurers must make certain they live up to their specific side of the insurance promise.  Coverage is for specified perils only.  Disability Insurers must be certain every applicant meets qualifying and coverage criteria before determining entitlement.  In the case of workers’ compensation, for example, the applicant must be an insured worker within the definition of the law or policy in force; because workers’ compensation insurance covers work-related injury and disease, the nexus between work and the harm leading to disability must be established.  If these criteria are met, the workers’ compensation insurer can then assess the extent of the loss, if any, and compensate the loss accordingly. 

It would be incorrect to simply view denied claims as either a reflection of heartless bureaucracies or a reasonable outcome of attempts by social insurance or workers’ compensation to guard against fraud, abuse or misuse.  The most common reasons for claims being rejected, denied or disallowed relate to issues of coverage, qualification and eligibility. 

Insurers do deny some claims wrongly.  Errors are made; we know that cases are overturned on appeal due to errors in law or judgement.  We also know that decisions take time; we also know that long delays are harmful.  Headlines about disability insurance denials are often sensational but the reasons are not always clearly explained; media reports often omit key facts or over-simplify the issues while privacy rules prevent full-throated clarification by insurers explaining their actions. 

The language of insurance

The trust gap is even reinforced by insurance terminology.  The technical language of disability insurance itself perpetuates negative perceptions. While “claimant” is a neutral term to insurers, in common parlance it has a negative connotation. “Claimant” implies a person has a contestable position and an onus to substantiate their “claim”.  It’s not just cynicism.  In everyday interactions, we learn to treat those “making a claim”  with caution and their “claim” with skepticism. 

In everyday conversations,  we typically ask a person making a claim to provide some evidence.  In disability terms, that ask is really an onus—typically placed on the disabled applicant.  That legal-sounding language is inherent in all disability insurance types.

All disability insurance demand evidence to consider in any application for benefits.  For insurance where causation is important, the  standard of proof may be as low.  For many workers’ compensation systems, the “work-relatedness”  need only meet the “balance of probabilities” standard; others require a higher standard such as work having been the “predominant cause”. 

For most group-LTD and social insurance, the question is less focused on  “causation” and more on  “disability”.  The onus for providing proof of disability typically rests with the applicant but is often mediated by the healthcare profession.  Questions of access to healthcare and the challenges of timely diagnosis and treatment are major barriers that can impede access to disability benefits.  Failure to provide required evidence may result in applications for benefits being suspended or denied. 

Why do disability insurers insist on applications to other disability insurers?

“Why bother claiming benefits from X when they will just reduce what I get from Y?”  Many disabled employees face this question.  The existence of multiple and sometimes overlapping disability insurance types drives the apparent high denial rates in social insurance and likely in some workers’ compensation systems as well.

The largest group LTD insurer in the US is Cigna.    The Group Long Term Disability application form [500469 Rev. 11/14 available at  https://www.cigna.com/static/www-cigna-com/docs/individuals-families/5004692.pdf ] for benefits includes the following:

Have you applied for Social Security Benefits?  Yes   No

If yes, please attach a copy of your Social Security notice for you and your dependents or a copy of your Social Security Denial.  If you have not applied, please do so as soon as possible.

Cigna also asks if the applicant is receiving or eligible for workers’ compensation, veterans’ benefits, no fault auto and other benefit plans.  In many cases, an affirmative response may reduce the amount payable under the group LTD coverage.

Where the benefits from a social insurance plan or workers’ compensation payment “offset” group LTD benefits, there is no advantage to the worker to claim both and no incentive to appeal a negative decision.  There is, however, a very clear advantage to the insurer if some other insurer is the “first payer”.  Where there is some stacking (partial integration or offsetting) of benefits, there is a clear financial incentive for disability insurance to press applicants to pursue coverage from all possible insurers.  Insurance principles generally preclude a person from being better off financially on disability insurance benefits than if working.

What can be done about this trust gap?

The reality of the disability insurance trust gap makes the job of case managers and other disability management professionals more difficult.  The attitudes and beliefs applicants bring with them may not be easily ameliorated; how benefit and rehabilitation people interact on an individual basis can overcome the trust deficit.  That’s the focus of Part 2.