Disability Insurance Blog

What Happens When Your Claims Adjuster is AI (Artificial Intelligence) Bot?

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Tuesday, March 23rd, 2021

AI software has been assisting with the processing of disability claims for several years, but you may not have noticed because there is still a human at the last leg of the claims process – the person who picks up the phone when you call the claims office in disbelief because your disability claim was denied or terminated.

Consider the volume of claims that come to insurance companies – it would take thousands of employees to manage physical files. With AI, claims are processed automatically, with values set for alerts to snare matters of concern – monthly benefits, conditions, age of claimant, expected duration of claim, etc.

The “claims adjuster” is making determinations about your future with zero emotion because they are not human. This is how large companies manage massive amounts of information.  AI is used to extract data from documents, organize huge amounts of information and respond to customer requests. When document processing and claims workflow is done by AI, mistakes made by humans entering manual data are eliminated. Settlement notifications and payments are handled by AI, with humans simply checking in on reports that measure every piece of the process, from claims volume, type, reasons for the disability claim, and any other metrics defined by the user to ascertain any part of the claims process.

One AI company claims that UNUM, Aetna, and CIGNA are all clients and is happy to promote its ability to reduce pending claims backlogs by automating the claims process entirely. Even contacting claimants has been automated, with the smart bots calculating the optimal time to reach them with bad news.

What does that mean for your disability claim? It means you need to change how you think about your claim.

First, stop thinking that a person is reviewing your claim file and imaging you and your family’s suffering. AI doesn’t work that way. There is no emotional response to the facts being scanned and analyzed by the system. There’s no emotion in the decision tree from the AI bots.

Second, your documentation needs to be heavily front-loaded. Every piece of information supporting your claim needs to be included: treating physician notes, declarations of your inability to perform the tasks of your job, job descriptions, diagnostic images, prescriptions, and documentation of side effects, etc.

Many claims are addressed on an “expected duration” which is data driven, but the data is provided by the same cohorts who utilize the data (the insurance companies).  Thus, they might suggest that for a heart attack with multiple stents, your expected duration of impairment is “15 days” – after which, they would expect you to return to work.  Perhaps that is the case – but perhaps you are an “outlier” – someone who is still impaired beyond an “expected duration”.  This is where your concerns must be resolved through strong medical support.  This support must address how and why are you are unable to return to work, with specificity.

Third, there are tests that your doctor may not have ordered for your condition. Your doctor’s decision to spare you the test might make or break your claim. We often find ourselves discussing our client’s medical conditions with doctors who didn’t recommend a particular type of test, feeling that it was not necessary because their patient’s disability was so apparent to them.  However, without the test, the disability insurance doesn’t have the data to make the decision in your favor. Here’s a recent case history that demonstrates the power of the right diagnostic test.

There’s not much you can do to prevent your disability claim from being processed by an automated AI system, but that’s all the more reason you need to be represented by experienced disability attorneys who understand what you are up against.   At all stages, claimants must remain vigilant and advocate for their claim.

 

Jason A. Newfield

Written By:

Jason A. Newfield

Disability Insurance Attorney