Updated: Apr 11
On the first day using DigitalOwl a carrier customer saved $20K when the DigitalOwl system identified medical findings that the physician missed on a claim.
I have written blog posts about how carriers saved $270,000 (here) and $150,000 (here) on illegitimate disability claims using the DigitalOwl system. Still, I like this case because it illustrates how quickly DigitalOwl can have an impact on risk management and claim analysis.
On the first day and on the first case using DigitalOwl, a false claim was identified.
Yana is an experienced claim analyst working in a big carrier's Disability and Accident claims department.
A year after buying the accident policy, a 44-year-old male filed a claim after he fell off a ladder and injured his right shoulder. The claim was for 10% disability of the right shoulder, and the policy had a total benefit of $200K.
Yana, the claim analyst, sent the insured's entire medical record to the carrier's physician to review the accident claim and the medical history.
On the same day that Yana received the summary back from the physician, she started working with the DigitalOwl system. The physician agreed that the right shoulder movement limitation and pain result in a 10% disability, and with no known medical history related to the shoulder, the claim should be approved.
Yana decided to analyze the medical record using the DigitalOwl system for the first time to see how it would work.
To Yana's surprise, the DigitalOwl system instantly identified that the insured had been suffering from continuous pain in his right shoulder before he bought his policy and had not declared it on his application - an important finding that the physician overlooked.
Therefore, Yana has now amended the policy to exclude the insured's right shoulder from his accident policy (as would have occurred at time of Underwriting) and rejected the claim. A savings of $20K.
Humans miss things - it's inevitable when reviewing dozens, hundreds or even thousands of pages of medical records. The DigitalOwl system is an important layer of protection for any underwriting, claim or related process where medical records are being reviewed and the final analysis is critical to the outcome.