Pathologists & Toxicologists – Key Factors in Managing the Rise in Life Claims

As life insurance claims increase, how will insurers respond?

While the full impact of COVID-19 is still being measured, one of the many industries still in flux is the life insurance industry. At the peak of the first wave of COVID-19, second quarter data from insurers reveals a drastic increase in life insurance claims compared to the same period in 2019. The causes of death may vary, but the expertise needed to properly adjudicate eligibility of life insurance claims has become even more critical.

Claim organizations must demonstrate agility and creativity to address the changing landscape and meet the expectations that come along with their commitment to fair and balanced risk management during a pandemic.

How pathologists & toxicologists fit in

Pathologists and toxicologists are an essential risk management tool used by claims professionals to accurately manage life insurance claims. Specifically, claims in which the policy includes a drug exclusion can be complex to adjudicate. When identifying the cause of death in such claims, a medical expert who is experienced in analyzing toxicology reports, autopsy reports, police reports, and/or a Coroner’s report can be critical to the evaluation.

When claim decisions are made without input from one of these specialists, errors in clinical pathology may not be discovered, leading to potentially incorrect life insurance claim determinations. If the appropriate tests are not ordered and/or test results are misinterpreted, the claim file may be documented with a misdiagnosis and any conclusions drawn from that documentation could be questionable.

Critical components of a pathology/toxicology file review

The following measures must be thoroughly evaluated by a pathology or toxicology expert to reach a correct diagnostic conclusion:

  1. Validation that the results are from the correct patient and the correct test was ordered and administered for the correct timeframe.
  2. Validation of the preparation, collection, transport, processing, and quality control procedures.
  3. Validation of the test results and interpretation of the findings. 

Pathology in life claims adjudication

The expertise of a pathologist can be crucial in assessing life claims where autopsy results and other postmortem examinations results are part of the medical record. An experienced pathologist, who understands the findings of an autopsy and other postmortem examinations, can bring important clarity to the cause and manner of death. 

The expertise of a board-certified forensic pathologist can assist in answering numerous questions which might be considered during a claim review, including:

Toxicology in life claims adjudication

A toxicologist’s expertise can be called upon when medically assessing life claims where medications, illegal drugs, non-prescribed medications, ethanol, poisons, and other substances are implicated in the death being investigated. 

A toxicologist can assist in answering questions related to if and how these substances may have impacted the death:

As the pandemic continues, the volume of claims requiring pathology and/or toxicology expertise is likely to increase as there are concerns that rates of suicide and drug overdoses may increase — or have already increased.

Sourcing a pathologist or toxicologist for your claim organization

Pathologists and toxicologists trained in file review are poised to analyze the available data and validate diagnostic determinations, which sets an accurate foundation for claim professionals to begin their evaluation.

PDA’s panel of consulting specialists includes board-certified pathologists and toxicologists at the doctoral level. The opinions of these experts can assist your claims professionals in understand the role of these substances as the cause of death, as a contributing cause, or as an innocent bystander.

Contact Sarah Lawsure, VP of Clinical & Vocational Services, to gain access to one of PDA’s expert specialists.

slawsure@pdamaine.com  |  (207) 747-4307