LIPS / API CLAIM DENIED

[Lascaille]

Tbird, I've read this whole thread from start to finish a couple of times now...

Correct me if I'm wrong - you (posting as footballfanppl) posted because your claim was extensively delayed. That claim later was rejected due to 'pre-existing conditions'. You indicate you have extensive, diverse or at the very least multiple medical opinions to the contrary. You've discovered there's no appeal process and you feel, to be blunt, screwed.

You're making some good points. The members should be concerned about there being no appeal process. The members should be concerned if a provider of professional services to the scheme isn't a member of their service's standard 'association' when the vast majority of other providers are.

On the other hand you are making some absolutely ridiculous howlers.

You 'asked a Senior Claims Consultant at Harvey Watt & Co as to whether they are a regulated company' and claim to have received the reply 'no we are not bound by ERISA' and based on that titled your post "PROOF LIPS API Appointed US based Assessor Harvey Watt & Co is Non Regulated".

ERISA is an American law. Why on earth would you even begin to expect it to apply to a scheme marketed to pilots based in the UAE? Also - why would somebody from a medical assessment firm ever think to say such a thing? Their employer (the scheme) would be the party to confirm or deny ERISA applicability.

I checked the Harvey Watt website and found they were based in Georgia. They claim to be a Licensed Third Party Administrator, I checked the Georgia state registry and was quite unsurprised to find them listed accordingly with 'active' status, license # 94153. Don't just take my word for it, check yourself. The website is www.oci.ga.gov

You can find them in 'insurers->search' as a Third Party Administrator and also in 'Agencies->Agency Search' as an agency.


As to their medical staff, I've had no correspondence with them so don't have any particular doctors to look up. I found a couple of names after trawling through some industry circulars and inserted them into the AMA's 'doctor finder' website, both came up as Aeromedical specialists.

You also repeated several times "Harvey Watt & Co receive commissions /renumeration from LIPS/API for case assessments with the amount Harvey Wayy & Co receive being dependent on percentage saved denying a pilots claim." It's a ridiculous thing to even suggest, isn't it? No reputable 'independent' third party firm would accept those terms. Even if you hypothecate up a situation where a 'reputable' firm took a contract on that basis, their doctors - much like pilots - are licensed personally and liable for malpractice personally. It's ridiculous.

Then you go on again to make a reasonable point - "Carrying on a regulated activity in the UK without authorisation or the benefit of an applicable exemption, such as effecting and carrying out contracts of insurance, is a criminal offence." That's a good point to follow up but you never did, you just ranted yourself down a hole claiming a 'conflict of interest' between CAMA and HW - if HW sponsor CAMA and a doctor who works for HW is a CAMA member there's only a conflict of interest if HW will gain or lose as a result of the decision. And if that were the case then - as explained above - merely being employed by HW would create a conflict of interest, forget CAMA.

"If Harvey Watt is making decisions, then surely legal liability should be with them, and the fund not be using pilot members' money to defend against legal action."

Giving a medical opinion isn't making a decision. If the trust has clear rules then they will be given a report template which maps to the trust rules. If trust rules are 'we pay out for all conditions barring angina and epilepsy' then their report template would just be two questions: 1. Is the debilitating illness angina? 2. Is the debilitating illness epilepsy? This is the only professional way to do it: the medical team shouldn't even know how the answers equate to a claim's success or failure, and of course all the files should be anonymised.

A pre-existing claim decision complicates matters - one doctor may see a file which says 'consistent right frontal headaches for 3 months in 2004, ten years later right frontal brain cancer' and say 'pre-existing' and another may look at the same file and say 'probably pre-existing but I can't prove it'.

You should focus your energy along these lines.

Here are some good questions:

• Are medical files anonymised prior to assessment?

• To the greatest extent possible is sex, age, religious or racially identifying information removed from the medical files before assessment?

• If the formatting or wording of some documents clearly indicates their origin in a way that may cause bias (imagine Syrian Air Force medical records) are they retyped or obfuscated?

• Is the medical team given a strict yes/no reporting format which matches only the trust rules?

• Does the reporting format disguise or randomise, where possible, questions and desired answers to avoid 'pattern bias' or 'result bias' (a person may be subconsciously inclined or disinclined to either tick yes 20 times in a row OR to tick no after ticking yes 20 times.)

• If a freeform report is produced is it possible that the reviewer would include biasing information unrelated to the larger claim. For example, a pilot may have a perfectly valid claim - something entirely physical such as a whole-arm amputation - but discover during their hospital visit they're HIV+. A fully comprehensive report in such a case produces bias risk.

• If there is a yes/no check box for a judgement based decision such as 'is this a pre-existing condition' are there clear written instructions readily to hand which specify the applicable standard such as 'beyond any reasonable doubt' or 'beyond mere balance of probability'?

• If a freeform report is produced containing the words 'in my opinion this is a pre-existing condition' then likewise - have they been instructed to only write that if they are convinced 'beyond a reasonable doubt' or can they write that if they are convinced 'beyond the balance of probability'?

• Who decided which standard is to be followed? for what reason?

• If a freeform report says 'it is likely that the condition is pre-existing' is the trust's decision going to to be consistently approve, consistently deny or a dice roll?

• Is a review risk mitigation process followed - such as having all evaluations performed separately by two randomly selected assessors followed by secret ballot?

• In the event of a tie requiring another reviewer, is the assignment of the other reviewer guaranteed to be entirely random and un-influenceable by the prior reviewers?

• Is a more senior reviewer selected in the event of a tie?

• If a reviewer's decision is overruled by a senior reviewer (once, twice, thrice) are their historical decisions audited?

Ask the questions that matter. The medical evaluation is your problem, so get stuck into it. Be systematic.

Don't ask ridiculous questions like 'Is it true that Aircrew Protection International are about to attempt to defend a major lawsuit in the Channel Islands using the pilot fund to finance same?'

• If they have no reason to think the trust rules have not been followed they are obliged to defend the trust assets, and remember, the loser pays everyone's legal fees.

• There will (should!) be zero provision in the trust rules for them to be able to pay you off or give you some shut-up money. If the rules allow this, uhoh.

I'm guessing some members want you to win and some want you to lose. I'm pretty damn sure no members want you to get paid off for being obnoxious.