Claims Review

This sample Claims Review is based on an actual review completed by IBU. The names, dates, identifying information and faciltities have all been changed.

Underwriter: Toni Koss
Date Completed: 9/26/2012

Name: Michael  Battier
Policy No U298888
Date Policy Applied For: 9/16/2010
Date of Death: 6/6/2012
APS Source: Original APS source unclear. Chart includes records from Mercy Hospital and Dr Waddell.
Claims Summary: CLAIM INFO: 17 pgs
Medical providers listed (pg 9):
Dr John Waddell (PCP)
Mercy Hospital
Dr Maureen Nelson
Cause of death: Respiratory failure, heart failure, liver failure, sepsis
Policy date: 9/23/10
Policy receipt: 11/7/10
Term life insurance app completed 9/16/10 (know before you go)--intelliScript and MIB search done
No MIB hits Replacing NYL
Face amount: 12,000
Application: Admits to CABG in 1990 (no specific details) and treated hypertension
MEDICAL RECORDS (Mercy Hospital and Dr Waddell)--120 pgs

Records date back to '02 (lab values), and end in 2/12. Medical history includes kidney stones (one on 12/18/06, and a prior history with no details), abnormal BUN and LFTs of unclear etiology (no mention of kidney or liver problems), mildly elevated blood sugar on past labwork (p96) with no official dx of diabetes noted, avascular necrosis of the L hip diagnosed in 4/07, psoriasis (no problems or meds taken in these records--noted as "gone"), mild intermittent anemia, multiple gastric ulcers, NSAID overuse, remote history of ITP following pneumovax immunization (no date), Hodgkins Lymphoma with chest radiation, chemotherapy, and splenectomy in approximately 1981 (conflicting info on exact date), chronic leukocytosis with a normal bone marrow biopsy in 2006 (exact date not given) and no further follow up needed, hyperplastic colon polyp in 4/05, hypothyroidism, hypertension, hyperlipidemia, R carotid bruit, bilateral carotid stenosis on 12/7/06 carotid US with L CAE in 5/11, remote history of MI (1990?), ASCVD with CABG in 1990, DES to the CX OM via SVG around 2004 (cardiac hx p18), tachycardia, arthritis, and sciatica. Tachycardia was noted to be asx on beta blocker. No other details on this history. Hospitalized from 12/4/06 to 12/8/06 for GI bleed with anemia (mostly likely related to the plavix and/or all the aleve he was taking for hip pain). EGD showed 2 gastric ulcers in the cardia of the stomach, mild gastritis, and duodenal bulb ulcer. He was given lortab for his sciatica/arthritis instead of aleve, and stopped the plavix. He has never smoked. Strong family hx of CAD. Lymphoma noted to be in remission in 12/06.

4/10 RX list (which is closest to the app date): prinivil, synthroid, zantac, lortab, lipitor, metaprol (p71)
Missing complete records from:
Cardiology (was seeing a Dr Carson at Advanced Cardiology --noted back in 12/06)
Dr Wheeler (taken from page 11 of the Claims info file)
Dr Gregory Rabeuf/ GI (it was mentioned that he was terminated as a patient some time after his '05 colonoscopy, but does not state when) (pg 72)
Dr Margaret Stimpson--seen for chronic leukocytosis and bone marrow biopsy in '06 (wnl), with no need for further follow up (p78)
Dr Klebe (pg 62)-- not clear why he saw this doctor

3/24/2009 72,73,76 SECTION II, #2: In the past 5 years; Have you been advised by a medical professional to have any tests, surgery, treatment, or any further medical evaluation that have not been performed, or do you have any medical test results pending? Answer: "no"
SOURCE: Dr Waddell

3/24/09: Dr notes history of "adenomatous" colon polyps---"needs to repeat colonoscopy in the next year or so"(p72) As of 1/11, apparently still not done (p73)
Of note: 4/05 colonoscopy revealed hyperplastic polyp (p15), so above
mention of "adenomatous" could be a typo. Previous colonoscopy was done in the 80's.

6/28/07: Advised to see ortho for avascular necrosis, but client did not want to follow through with that (p76). Eventual need for hip replacement was noted (when lortab no longer works).

12/6/2006 4 SECTION II, 1c: In the past 5 years; Other than preventative, maintenence, or risk lowering medications prescribed, have you been diagnosed or treated for heart or circulatory disorder (except controlled hypertension) or stroke? Answer: "no"
SOURCE: Mercy Hospital

Bilateral carotid stenosis 50-79% on 12/7/06 carotid US (p4). He eventually had L CAE in 5/11.