Disability Claim Policies & Procedures

1 Disability Claim Policies and Procedures Disability Claim Policies &. Procedures Please be aware that the guidelines in this publication are intended to be considered by New york Life Group Benefit Solutions Claim professionals as a reference and guideline for evaluating and managing claims. Each Claim is unique, and should be evaluated and managed considering these guidelines, combined with the expertise and judgment of the reviewer, taking into account the specific details of that Claim and the specific language of the policy/plan. If there is any inconsistency between the policy/plan, and the information in this publication, the policy/plan will govern. The material in this publication is considered proprietary and confidential. This publication is intended for personal use only and further distribution or non-personal use is strictly prohibited. Confidential, property of New york Life Insurance Company.

2 Do not duplicate or distribute. See Terms and Conditions for more information governing your use of this publication. 2021 New york Life Insurance Company, New york , NY. All rights reserved. NEW york LIFE and the New york Life box logo are registered trademarks of New york Life Insurance Company. New york Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America and New york Life Group Insurance Company of NY, subsidiaries of New york Life Insurance Company. Disability Claim Policies and Procedures Disability Claim Policies AND Procedures . BACK TO TABLE OF CONTENTS TABLE OF CONTENTS. Disability Claim Policies AND 2. BACK TO TABLE OF CONTENTS TABLE OF CONTENTS .. 2. NEW york LIFE GROUP BENEFIT SOLUTIONS Disability Claim PRACTICES .. 4. ACTIVE SERVICE AND ELIGIBILITY FOR SHORT TERM Disability AND LONG TERM Disability .

3 6. ACTIVE SERVICE AND TAKEOVER PROVISIONS FOR LIFE Policies .. 11. ADVERSE Claim DETERMINATION GUIDELINES FOR Policies PROVIDING Disability BENEFITS .. 15. ADVERSE DETERMINATION LETTER CONTENT FOR Policies PROVIDING Disability BENEFITS .. 17. ANY OCCUPATION INVESTIGATION GUIDELINES .. 23. APPEAL AFFIRMATION LETTER CONTENT FOR Policies PROVIDING Disability BENEFITS .. 27. APPROPRIATE CARE .. 31. Claim MANAGER APPEAL WORKFLOW .. 34. ELIGIBILITY REVIEW FOR WAIVER OF PREMIUM CLAIMS .. 37. ELIMINATION PERIOD AND BENEFIT START DATE .. 39. ERISA GUIDELINES FOR Policies PROVIDING Disability BENEFITS .. 43. EVALUATING Disability AS OF LAST DAY WORKED .. 48. EVALUATING JOB OR OCCUPATION REQUIREMENTS .. 51. EVALUATING OWN OCCUPATION IN CALIFORNIA ISSUED LONG TERM Disability Policies .. 53. EXTENDED DEATH BENEFIT WITH WAIVER OF 56. FUNCTIONAL CAPACITY EVALUATION REFERRALS.

4 60. GATHERING MEDICAL INFORMATION AND DOCUMENTING CONCLUSIONS .. 62. GUIDELINES FOR USE OF EXTERNAL MEDICAL RESOURCES .. 69. INDEPENDENT MEDICAL EVALUATION AND PEER REVIEW REFERRALS .. 72. LATE SUBMITTALS .. 75. LIFE WAIVER OF PREMIUM ANY OCCUPATION EVALUATIONS .. 81. LONG TERM Disability EXPERT RESOURCE MEDICAL REVIEW .. 83. MENTAL ILLNESS AND 9TH CIRCUIT GUIDELINES .. 87. MENTAL ILLNESS LIMITATION REQUIREMENTS AND INVESTIGATION Procedures .. 88. MODIFIED OCCUPATION .. 93. Confidential, property of New york Life Insurance Company. Do not duplicate or distribute. See Terms and Conditions for more information governing your use of this publication. 2021, New york Life Insurance Company, New york , NY. All rights reserved. NEW york LIFE and the New york Life box logo are registered trademarks of New york Life Insurance Company. New york Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America and New york Life Group Insurance of NY, subsidiaries of New york Life insurance Company.

5 2. Disability Claim Policies and Procedures ONGOING Claim REQUEST FOR INFORMATION .. 96. POLICY EXCLUSIONS BASED ON MEDICAL 100. PRE-EXISTING CONDITION LIMITATION AND 102. PREGNANCY LEAVE GUIDELINES .. 112. PROOF OF LOSS FOR CALIFORNIA-ISSUED LONG TERM Disability Policies .. 118. RECEIPT OF Claim FOR LINKED LIFE WAIVER OF PREMIUM .. 120. RECEIPT OF Claim OR APPEAL .. 122. RECEIPT OF NEW INFORMATION ON ADVERSELY DETERMINED CLAIMS WHEN NO APPEAL HAS BEEN FILED .. 124. RECEIPT OF NEW INFORMATION ON CLOSED 126. RELEASE OF INFORMATION FROM GROUP OPERATIONS Policies AND Procedures .. 128. REQUIREMENTS FOR HANDLING Disability APPEALS .. 133. SECOND EYE REVIEWS LONG TERM Disability .. 140. SECOND EYE REVIEWS SHORT TERM Disability .. 142. SHORT TERM Disability AND SOCIAL SECURITY AWARDS .. 143. SHORT TERM Disability EXPERT RESOURCE MEDICAL 145. SOCIAL SECURITY AWARDS AND Disability DETERMINATIONS.

6 146. STATE COMPLIANCE GUIDELINES FOR Policies PROVIDING Disability BENEFITS .. 152. TRANSFERRABLE SKILLS ANALYSIS AND LABOR MARKET SURVEY REFERRAL PROCESS .. 156. WAR AND TERRORISM EXCLUSIONS .. 159. WORKERS COMPENSATION AND THE LONG TERM Disability EVALUATION .. 161. WORKERS COMPENSATION AND WORK-RELATED EXCLUSIONS AND THE SHORT TERM Disability EVALUATION.. 166. CONFIDENTIALITY AND DISCLAIMER .. 171. Confidential, property of New york Life Insurance Company. Do not duplicate or distribute. See Terms and Conditions for more information governing your use of this publication. 2021, New york Life Insurance Company, New york , NY. All rights reserved. NEW york LIFE and the New york Life box logo are registered trademarks of New york Life Insurance Company. New york Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America and New york Life Group Insurance of NY, subsidiaries of New york Life insurance Company.

7 3. Disability Claim Policies and Procedures New york Life Group Benefit Solutions Disability Claim Practices Purpose/Overview Disability Claims and Claim Professionals Purpose of Policies and Procedures Commitment in Administering Claims Integrity, Impartiality and Independence Disclosure of P&Ps and Reliance on P&Ps Purpose/Overview The purpose of these guidelines is to discuss New york Life Group Benefit Solutions' (NYL. GBS) commitment to providing prompt, fair, consistent and unbiased administration of Disability claims. Disability Claims and Claim Professionals This guideline applies to NYL GBS employees who have substantive involvement in the Disability Claim process. A Claim is a Disability Claim if the benefit is conditioned on a showing of Disability , or requires the Claim manager to make a determination of Disability to decide the Claim . This includes a Claim for Short-term Disability , Long-term Disability , and Waiver of premium under a life insurance policy.

8 Purpose of Policies and Procedures The Policies and Procedures (P&Ps) provide guidelines for the manner in which NYL GBS. administers Disability claims. They contain administrative processes and safeguards designed to promote the goal of consistent Claim administration across similarly situated claims in accordance with applicable federal and state regulations and the governing policy/plan provisions. The P&Ps are not intended to be a set of absolute rules. Claim professionals are expected to use their experience and judgment in applying the P&Ps to the administration of a particular Claim . Exceptions may be necessary due to a Claim 's particular circumstances, or applicable plan provisions. If there is any inconsistency between the policy/plan, and the information in these Procedures , the policy/plan will govern. Commitment In Administering Claims Confidential, property of New york Life Insurance Company.

9 Do not duplicate or distribute. See Terms and Conditions for more information governing your use of this publication. 2021, New york Life Insurance Company, New york , NY. All rights reserved. NEW york LIFE and the New york Life box logo are registered trademarks of New york Life Insurance Company. New york Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America and New york Life Group Insurance of NY, subsidiaries of New york Life insurance Company. 4. Disability Claim Policies and Procedures Claims professionals are expected to evaluate all claims completely and thoroughly, by using their best efforts to obtain necessary information, and to make an accurate determination by applying the available information and analysis to the terms of the policy/plan. If the evidence demonstrates that the Claim should be paid under the terms of the policy/plan, then the Claim should promptly be approved.

10 If the evidence demonstrates that the Claim should not be paid under the terms of the policy/plan, then the Claim should promptly be denied. Integrity, Impartiality and Independence NYL GBS expects its claims professionals to maintain the highest standards of integrity, impartiality and independence. No employee, policyholder or any other person can influence the evaluation or determination of a Claim or appeal based on considerations other than the evidence and the terms of the policy/plan. NYL GBS will never make an employment-related decision related to its employees based on whether an employee has denied or approved, or is likely to deny or approve, one or more claims for Disability benefits. This includes decisions regarding hiring, compensation, promotion, termination or other similar matters. NYL GBS employees should report any concerns to their manager or the NYL Ethics Hotline.