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Fellow, Life and Health Claims (FLHC)

Advanced selected learning in life-and-health claims, service, underwriting context, regulation, and planning. FLHC is an ICA designation built on the complete ALHC curriculum plus additional courses.

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ALHC foundation plus added customer service, marketing, underwriting, and elective courses

A group disability claim meets the medical definition, but the claimant has not completed the policy’s 90-day elimination period. What is the current entitlement?

A group disability claim meets the medical definition, but the claimant has not completed the policy’s 90-day elimination period. What is the current entitlement?ADo not start periodic benefits before the elimination period is satisfied; continue verification under the policy.BPay as soon as one record supports part of the claim.CDeny solely because records conflict.DCollect all available medical records regardless of relevance.

Own-occupation and any-occupation tests

An own-occupation definition asks whether illness or injury prevents the insured from performing the material duties of the occupation specified by the contract. An any-occupation test may apply later and asks whether the person can perform suitable work under the policy's education, training, and experience standard. Establish the applicable stage, actual duties, functional limits, and required proof; a diagnosis alone does not settle either test.

Worked example

A surgeon unable to operate may meet an own-occupation test while retaining capacity for other work. Whether that satisfies a later any-occupation test depends on the exact definition and vocational evidence.

Calculate the capped benefit and offset

Apply the policy formula in order: eligible pre-disability earnings times the replacement percentage, then the contractual maximum, then verified offsets if the wording requires that sequence. Do not treat an estimate or unverified public benefit as an established offset. Show each step so the claimant and reviewer can reproduce the provisional amount; confirm earnings basis, cap, offset definition, and effective date in the certificate.

Worked example

$10,000 monthly earnings × 60% = $6,000; the $5,000 cap reduces it to $5,000; a verified $1,500 offset leaves a provisional $3,500, subject to policy terms.

Reconcile partial-disability earnings

For partial disability, compare verified current earnings with the contract's pre-disability earnings basis for the relevant period. Then apply the policy's loss-percentage or other partial-benefit formula and determine whether offsets apply before or after that calculation. Variable pay, return-to-work dates, and eligible earnings definitions can change the result, so reconcile payroll periods rather than relying on a single monthly snapshot.

Worked example

If earnings fall from $10,000 to $6,000, the loss is 40%. Under a proportional formula, 40% × a $5,000 capped benefit = $2,000 before any applicable offset; the contract controls.

Separate reserve judgment from entitlement

A reserve estimates the expected future cost of an open claim; it is not a finding that every future benefit is payable. Worsening prognosis, delayed recovery, or new functional evidence may change duration and amount assumptions. Reassess the reserve transparently while deciding eligibility under the contract on relevant evidence. If the claimant disputes the decision and supplies material new records, arrange a fair review by an appropriately independent medical or vocational reviewer.

Worked example

A revised recovery estimate may increase the expected claim duration and reserve today, while the next benefit decision still depends on proof for the applicable policy period.

FLHC

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Contractual disability test

Identify the definition, stage, occupation, and proof required for the period.

Own occupation

Use the own-occupation definition to the specified job's material duties; inability to perform one task matters only if the contract's test is met.

Apply it: Example: a surgeon cannot operate but can teach; own-occupation and any-occupation tests may differ under the policy wording.

Any occupation

At the any-occupation stage, assess suitable work using the policy's education, training, and experience standard rather than assuming any job qualifies.

Evidence

Combine clinical restrictions with actual duties and vocational facts; a diagnosis alone cannot establish functional inability or satisfy the contractual test.

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Eligibility and waiting period

Separate disability evidence from the time condition for benefit commencement.

Trigger date

Establish the date qualifying disability began, because it starts the elimination-period calculation and determines which policy terms govern. Record the start date and supporting evidence before counting begins.

Apply it: Example: count a 90-day elimination period from the contractual start date; confirm interruption rules before setting first payable day.

Day count

Count qualifying days using the contract's interruption and recurrence rules; a calendar shortcut can move the earliest payable date. Apply contract rules for interruptions rather than restarting by assumption.

Period proof

Verify continuing proof for each benefit period; approval for an earlier month does not automatically establish entitlement later. Request updated proof when function or work capacity changes.

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Benefit computation

Use verified income and the policy?s exact calculation order.

Replacement rate

Apply the stated replacement percentage to eligible pre-disability earnings; exclude amounts the contract does not treat as covered income. Confirm covered earnings before applying the cap.

Apply it: Example: $10,000 × 60% caps at $5,000, then a verified $1,500 offset leaves $3,500 provisionally payable.

Maximum and offsets

Apply the maximum and verified offsets in contractual order; unsupported assumptions about other benefits can wrongly reduce payment. An unverified offset can understate the claimant's payment.

Partial disability

For partial disability, reconcile period earnings and apply the policy formula; a single inconsistent payslip may distort the loss percentage.

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Life and health claim evidence

Resolve entitlement with authenticated, relevant records.

Beneficiary

Compare authenticated beneficiary forms by validity and date; an apparent later form may be ineffective if execution requirements were not met.

Apply it: Example: two authenticated beneficiary forms conflict; pause payment and verify validity, chronology, and any required legal review.

Medical proof

Request medical records connected to the insured event and definition; broad unrelated requests increase delay without improving the decision. Link each request to a specific eligibility question.

Coordination

Coordinate overlapping policies only under their own wording; do not assume one plan's offset or definition controls another's benefit. Separate policy terms prevent an unsupported deduction.

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Reserving and claim management

Estimate future cost while preserving independent entitlement decisions.

Duration assumptions

Update expected duration when prognosis or function changes; document the basis so reserve movements can be explained and reviewed. Tie each change to new clinical or functional evidence.

Apply it: Example: worsening prognosis extends expected duration; revise reserve assumptions while leaving contractual eligibility open for review.

Reserve basis

Record uncertainty, assumptions, and review triggers separately from eligibility; a higher reserve is not proof that benefits are payable. This keeps financial estimation distinct from contractual adjudication.

Separate decisions

Make the contractual entitlement decision from evidence for each period; a reserve estimate should neither approve nor deny the claim.

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Fair review and governance

Provide a reasoned, traceable process when evidence or decisions are challenged.

New records

Assess new records for relevance and materiality even when submitted late; explain what changes or does not change in the decision.

Apply it: Example: a new vocational report challenges denial; obtain independent review and explain how the appeal considers that evidence.

Independent review

Use appropriately independent medical or vocational expertise when the dispute requires it; define the question and share relevant evidence. Independent expertise can test disputed function without predetermining coverage.

Appeal path

Explain appeal steps, timeframes, and reasons respectfully; a traceable review can correct error while preserving a fair process. The written reasons should address the evidence raised on appeal.

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Your free concept lesson

Advanced group disability claim: from definition to dispute

A connected group disability claim follows contract interpretation, waiting-period arithmetic, benefit and offset calculations, partial earnings, reserve review, and a fair dispute process.

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Start with the contract

An employee stops work with a documented illness and files a group disability claim. The first question is not simply whether a diagnosis exists. Read the contract’s disability definition: own occupation, any occupation, or a staged change after a stated period. Confirm the covered person, elimination period, earnings basis, and required proof. Medical evidence supports functional limits; it does not replace the policy test.

Count the waiting period

The file supports disability beginning April 1, and the certificate states a 90-day elimination period. If the contract counts April 1 as day one, April has 30 days, May adds 31, and June 29 completes day 90. Benefits cannot begin before the period is satisfied; the earliest payable date may be June 30 under that counting assumption. Verify the contract’s day-count and proof rules before fixing the date.

Calculate the initial benefit

Assume verified pre-disability earnings are $10,000 per month. Sixty percent is $6,000, but the contract caps the monthly benefit at $5,000. If a verified $1,500 offset applies, the provisional payable amount is $3,500 per month. Show each step separately and confirm which income counts as an offset. This calculation is conditional on the definition, waiting period, proof, and coordination terms being satisfied.

Reconcile partial disability

Later, the employee returns part-time and earns $6,000 monthly against a verified pre-disability base of $10,000, a 40% earnings loss. If the contract pays in proportion to lost earnings, 40% of the $5,000 capped benefit is $2,000 before offsets. Do not carry forward the full-disability amount. Verify eligible earnings, the partial-disability definition, and whether the $1,500 offset applies before or after this formula.

Reassess the reserve

A specialist report now describes a worsening prognosis and uncertain return-to-work timing. The claim manager should reassess expected benefit duration, functional evidence, rehabilitation prospects, and the reserve assumptions, documenting what changed and when another review is due. A higher reserve reflects expected claim cost under current information; it does not prove eligibility or predetermine the final duration. Keep entitlement analysis and financial estimation distinct.

Resolve the dispute fairly

The claimant disputes the partial-benefit calculation and submits a new occupational assessment. Reopen the relevant issue, test the report against the contract’s functional definition, reconcile it with medical and earnings evidence, and obtain independent clinical or vocational review when needed. Explain the review path, preserve the claimant’s response, and document why the new evidence changes—or does not change—the calculation. A fair dispute process is reasoned, timely, and traceable.

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