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: 10/10/2012

Name: Sarah  Marcus
Policy No U36999
Date Policy Applied For: 12/6/11
Date of Death: 6/18/12
APS Source: Good Faith Nursing Home
Knoxville General Hospital
Northern Medical Center

Claims Summary: UW FILE--19 pgs:
Application signed 12/6/11
Face amount = $5,000
Express Issue Premiere
All questions are answered no. No adverse medical history is noted.
No MIB hit and no prescriptions found
CLAIM FILE--5 pgs:
Date of death: 6/18/12 (age 72)
Death certificate cause of death: Acute respiratory arrest. Hypovolemic shock. GI hemorrhage.
Physicians listed:
Dr Greg O'Neill
Dr Susan Bledsoe
APS--Good Faith Nursing Home (records are from 5/12 to 6/12 only, and include some records from Southern Hills Med Ctr and Knoxville General Hospital)--40 pgs:

History includes hypertension, R mastectomy with chemo and radiation for breast cancer around '88 (p17), kidney stone, stage IV CKD, granulomatous dz of the spleen, and memory impairment/altered mental status.

5/25/12: (Knoxville General Hospital): C/o generalized weakness, diarrhea, fecal incontinence, and poor appetite for some time now. Single. Never been married and has 3 children. Lives alone. She was found by her daughter to be significantly weak and not able to move around. History of CKD which has been evaluated by a Dr Forrest here at the nephrology clinic (dates not given). (p20) CT head revealed no acute abnormality, age related brain atrophy, and periventricular white matter c/w chronic small vessel ischemic dz (p37).

6/1/12: (Good Faith Nursing Home and Rehab): Admitted for rehabilitation from 5/12 episode of diarrhea with associated generalized weakness. Weight=122 lbs CT abdomen revealed fecal impaction which was manually disimpacted. Received blood transfusion for severe anemia.

6/11/12: (Southern Hills Med Ctr): Presented with hypovalemic shock, BP 65/30, originally in SR, now in Afib. Also has acute renal failure w/ cr of 3.2, and hemoccult positive. Apparently this am, she was unresponsive. Recently admitted to Good Faith Nursing Home. She is severely hypotensive-- and during the assessment, went from sinus tachycardia to atrial fib with rapid ventricular response. She rec'd a bolus of cardizem and started on IV fluid. Poor appetite and unsteady gait noted. HX: Generalized weakness, failure to thrive, HTN, anemia, CKD, and breast cancer. (p9) Her family elected to make a DNR should she go into cardiac arrest. She was observed to be very frail and extremely cachectic (p11). Altered mental status most likely from GI bleed. Afib, and overall poor state of health. Should she maintain hemodynamics, will evaluate the leukocytosis, as dr believes the patient might have an occult malignancy. (p11)
Impression: Hypovolemic shock. Acute GI bleed. Acute and chronic renal failure. Failure to thrive, with cachexia.

6/12/12: Consults with Dr McMahon and Dr Cohen regarding above hospitalizations: Constipation with distended colon. Evidence of chronic large colonic obstruction secondary to fecal impaction, with apparently non-functional sigmoid and rectum. She was not in good general condition to withstand the large surgery for removal of her colon and rectum. Unsuccessful attempts were made to contact the family regarding treatment options. May treat with comfort measures only. Continue antibiotics given the patient's leukocytosis and bandemia. Weight: 80 lbs (p16)
APS--Knoxville General Hospital--100 pgs: Records cover 6/10-5/12 . History of bilateral leg swelling, venous stasis, HTN x 4 yrs, CKD since at least 6/10 (p8), R breast cancer in '88, stable benign L breast subareolar nodule on 6/10 mammo (p12--no other details given), glaucoma, anemia that apparently dates back to the time of her breast cancer (p58), and significant weight loss over the past year. She was referred to nephrology for the CKD in 1/11(p37) and again in 2/11 (p27), but she didn't see nephrology until 3/12.
Notable build history:
10/10=162 lbs(p22), 2/11=174 lbs(p27) No build info again until 1/26/12=141 lbs (p35)
5/12=122 lbs
APS--Northern Medical Center--37 pgs:

Admitted 6/11/12 with altered mental status. Details of hospitalization are noted above. Discharged 6/15/12 with diagnosis of: GI bleed. Altered mental status. Atrial fibrillation. Failure to thrive/malnutrition. Chronic large colonic obstruction secondary to fecal impaction with apparently non-functional sigmoid and rectum. Chronic renal insufficiency. Hypertension. Heme positive stool. Hypovolemic shock. She was transferred back to Good Samaritan for further hospice care.
Records cover 6/11/12 to 6/15/12 timeframe (p2-3)

6/12 RX list: HCTZ, ferrous sulfate, docusate, nystatin, morphine, acetaminophen

Would suggest ordering the following missing records if not already done so:
Dr O'Neill (listed on pg 3 of the claims file)
Dr Susan Bledsoe (listed on pg 3 of the claims file)

5/20/2012 7,17,22,27,29,31,37,47,48,54 SECTION II.A.1.e: In the past 2 years, have you been treated for, or are you currently under treatment for: Sickle cell anemia, or kidney disease (including dialysis) or liver disease (including hepatitis B and C)? ANSWER: "No"


6/24/10: DX: "Renal insuffiency" (p7) KFTs pg 6.

8/26/10: DX: "Renal insufficiency" (p17) KFTs pg 21

10/14/10: DX: "Renal insufficiency" (p22) KFTs p26

1/26/11: DX: "Chronic renal disease" (p37) Referred to nephrology.

2/17/11: DX: Uncontrolled HTN. "CKD" (p27) Referred to nephrology. (p29)

3/17/11: DX: Uncontrolled HTN. "CKD" (p31)

3/6/12: Nephrology/ Dr Forrest: "Hx of CKD, she states for at least 1 year" (p47)
DX: CKD, stage 4, stable. She has had natural progression of her renal disease.
Plan: Renal US. RTC 3 mos (p48)

5/10/12: DX: "Stage 4 CKD" (p54)

2/17/2011 27,29,31 SECTION II.A.2: In the past 2 years, have you been advised by a medical professional to have any tests, surgery, treatment, or further medical evaluation that have not been performed or do you have any medical test results pending?


1/26/11: DX: "Chronic renal disease" (p37) Referred to nephrology.

2/17/11: DX: Uncontrolled HTN. "CKD" (p27) Referred to nephrology. (p29)

****She was referred to nephrology in early '11, as noted above, but not initially seen until 3/12.