Common use of Monitoring of Compliance with Revised Claim Procedures Clause in Contracts

Monitoring of Compliance with Revised Claim Procedures. The Lead Regulators shall monitor compliance with the changes in claim procedures set forth in paragraphs B.3.b. through B.3.g. above and may conduct examinations of claims in the manner and at such intervals as the Lead Regulators deem appropriate. The DOL may monitor compliance with changes in claim procedures set forth in paragraphs B.3.b. through B.3.g above and may conduct examinations of claims in the manner and at such intervals as the DOL deems appropriate. The examinations of claims will include but not be limited to review of claim files for the following problems, including failure to: • Conduct a field visit where circumstances warrant; • Obtain complete medical records; • Fairly interpret or apply information from the claimant’s AP; • Use appropriate in­house medical resources; • Fairly interpret or apply in­house medical opinions; • Contact AP where circumstances warrant; • Conduct appropriate occupational review; • Obtain an IME or FCE where circumstances warrant; • Select individuals to conduct XXXx and FCEs solely on the basis of objective, professional criteria, and without regard to results of previous XXXx or FCEs; • Fairly interpret or apply IME or FCE results; • Appropriately classify disabilities under the mental and nervous limitation provisions of its policies; or • Follow Company claim procedures or other Company procedures. Claim files will also be examined for evidence of: • Reliance on lack of “objective” data or “objective” medical information as a basis for claim denial or termination of benefits; • Faulty or overly restrictive interpretation or application of policy provisions, including the definition of “occupation” in “own occupation” policies; • Actions suggesting a pre­disposition or bias against the claimant; • Threats to seek repayment of past benefits; • Forcing claimants to seek legal counsel to obtain benefits; or • Evidence of any incentives provided to deny or terminate benefits.

Monitoring of Compliance with Revised Claim Procedures. The Lead Regulators shall monitor compliance with the changes in claim procedures set forth in paragraphs B.3.b. through B.3.g. above and may conduct examinations of claims in the manner and at such intervals as the Lead Regulators deem appropriate. The DOL may monitor compliance with changes in claim procedures set forth in paragraphs B.3.b. through B.3.g above and may conduct examinations of claims in the manner and at such intervals as the DOL deems appropriate. The examinations of claims will include but not be limited to review of claim files for the following problems, including failure to: • Conduct a field visit where circumstances warrant; • Obtain complete medical records; • Fairly interpret or apply information from the claimant’s AP; • Use appropriate in­house in-house medical resources; • Fairly interpret or apply in­house in-house medical opinions; • Contact AP where circumstances warrant; • Conduct appropriate occupational review; • Obtain an IME or FCE where circumstances warrant; • Select individuals to conduct XXXx and FCEs solely on the basis of objective, professional criteria, and without regard to results of previous XXXx or FCEs; • Fairly interpret or apply IME or FCE results; • Appropriately classify disabilities under the mental and nervous limitation provisions of its policies; or • Follow Company claim procedures or other Company procedures. Claim files will also be examined for evidence of: • Reliance on lack of “objective” data or “objective” medical information as a basis for claim denial or termination of benefits; • Faulty or overly restrictive interpretation or application of policy provisions, including the definition of “occupation” in “own occupation” policies; • Actions suggesting a pre­disposition pre-disposition or bias against the claimant; • Threats to seek repayment of past benefits; • Forcing claimants to seek legal counsel to obtain benefits; or • Evidence of any incentives provided to deny or terminate benefits.

Monitoring of Compliance with Revised Claim Procedures. The Lead Regulators shall monitor compliance with the changes in claim procedures set forth in paragraphs B.3.b. through B.3.g. above and may conduct examinations of claims in the manner and at such intervals as the Lead Regulators deem appropriate. The DOL may monitor compliance with changes in claim procedures set forth in paragraphs B.3.b. through B.3.g above and may conduct examinations of claims in the manner and at such intervals as the DOL deems appropriate. The examinations of claims will include but not be limited to review of claim files for the following problems, including failure to: • Conduct a field visit where circumstances warrant; • Obtain complete medical records; • Fairly interpret or apply information from the claimant’s AP; • Use appropriate in­house medical resources; • Fairly interpret or apply in­house medical opinions; • Contact AP where circumstances warrant; • Conduct appropriate occupational review; • Obtain an IME or FCE where circumstances warrant; • Select individuals to conduct XXXx and FCEs solely on the basis of objective, professional criteria, and without regard to results of previous XXXx or FCEs; • Fairly interpret or apply IME or FCE results; • Appropriately classify disabilities under the mental and nervous limitation provisions of its policies; or • Follow Company UnumProvident Companies claim procedures or other Company UnumProvident Companies procedures. Claim files will also be examined for evidence of: • Reliance on lack of “objective” data or “objective” medical information as a basis for claim denial or termination of benefits; • Faulty or overly restrictive interpretation or application of policy provisions, including the definition of “occupation” in “own occupation” policies; • Actions suggesting a pre­disposition or bias against the claimant; • Threats to seek repayment of past benefits; • Forcing claimants to seek legal counsel to obtain benefits; or • Evidence of any incentives provided to deny or terminate benefits.