LIPS / API CLAIM DENIED

[Thunderbirds54321]

Lascalle: your view requested on API Appeal Procedure

Thank you for your detailed response.

The night before your post below a meeting was hosted for an aggrieved declined claimant (name withheld for now for confidentiality) . This Captain concerned met to obtain information to initiate a lawsuit. He stated he had been wrongly declined for benefit based on a claim of pre existing condition cited by Harvey Watt & Co and was provided with details of legal counsel to support pursuance of his case. The individual concerned stated that in response to his contestation of denial he had received a call from a CPT JP from API who on being advised of intention to sue stated he would be in touch. Two weeks after this meeting the individual concerned was advised the decision had been reversed and his claim was approved overruling Harvey Watt & Co “recommendation".

Originally Posted by 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.

1. PURPOSE OF THE APPEAL PROCESS.

1.1. API hopes that any disputes, if they arise, can be resolved with as little inconvenience and delay as possible. To that end, the API Plan Rules provide a procedure whereby a Member may appeal an Initial Benefit Determination.

1. THE INITIAL BENEFIT DETERMINATION
   1. 2.1. The Initial Benefit Determination is made entirely at the discretion of the Trustee and is based upon the guidance contained in the recommendation of the Trustee’s Medical Advisor (the“Recommendation”) and the API Plan Rules, and shall be consistent with the applicable laws of the Island of Guernsey (“Guernsey Law”) and the regulations set forth by the Guernsey Financial Services Commission (the “GFSC Regulation(s)”).
   2. 2.2. When deliberating how to implement the Recommendation, the Trustee give full consideration to any conflicts between the Recommendation and Guernsey Law, the GFSC Regulations and the API Plan Rules, all of which govern how the Trustee administers the Plan. In the event of a conflict between the Recommendation and any Guernsey Law, GFSC Regulation or API Plan Rule, the relevant Guernsey Law, GFSC Regulation or API Plan Rule shall govern.
   3. 2.3. In carrying out its respective responsibilities, the Trustee shall have the sole discretion to interpret the API Plan Rules and to determine the eligibility for an entitlement to any benefits under the API Plan.
   4. 2.4. The Trustee has sole discretion to interpret the API Plan Rules in deciding whether to allow any appeal, determining the outcome of any appeal, and make all benefit determinations.
   5. 2.5. Any interpretation or determination made pursuant to the discretionary authority of the Trustee shall be given full force and effect except as set forth to the contrary herein.
   6. 2.6. For the avoidance of doubt benefits under the API Plan shall only be payable if the Trustee, in its sole discretion, decides that the Member is entitled to them.
2. SUBMISSION OF APPEAL.
   1. 3.1. Timeline: If a Member wishes to dispute an Initial Benefit Determination, he or she must initiate a request for appeal within 90-calendar days after receiving their Notice of Entitlement or notice that the claim has been denied. All requests should be submitted to API the Trustee using the following email address: [email protected]. Any request received by API after this 90-calendar day filing period will be denied.
   2. 3.2. Evidence:
      1. 3.2.1. The revocation of a Class I Medical Certificate by the GCAA (or other respective regulatory body) is made by an autonomous regulator and is based upon the Medical Certificate Revocation Documents.
      2. 3.2.2. It is outside the control and authority of API and the Trustee.
      3. 3.2.3. The Recommendation, which the Trustee considers in making its Initial Benefit Determination, is also made on the basis of the Medical Certificate Revocation Documents and any reports or correspondence furnished to the Trustee’s MedicalAdvisor by the review board of the GCCA (or respective aviation regulatory body) pursuant to their review (where applicable).

1. 3.2.4. In support of any appeal, a Member may submit additional evidence, provided that any evidence presented by the Member must be received within the 90 calendar day filing period referenced in section 3.1 above and must pre-date the Revocation Date.
2. 3.2.5. Any evidence which post-dates the Revocation Date would not have been considered by the GCAA (or other respective regulatory body) and, therefore, cannot beconsidered by the Trustee’s Medical Advisor or the Trustee.

1. THE APPEAL PROCESS – STAGE 1 – TRUSTEE RE-EVALUATION.
   1. 4.1. Where a Member wishes to appeal an Initial Benefit Determination, he or she may do so by requesting the Trustee to exercise its discretion to conduct a re-evaluation of the Member’sclaim in the first instance.
   2. 4.2. The Trustee will only conduct a re-evaluation based upon the provision by the Member of new evidence (as described in 3.2 above), and only if the Trustee, in its sole discretion, decides on the balance of the evidence provided it is necessary to do so.
   3. 4.3. In conducting its reassessment, The Trustee may seek guidance or clarification from theTrustee’s Medical Adviser, the Consultants to the API Trust, the Plan administrators and its consultants, the accountants contracted to the Trust and / or the attorneys contracted by the API Trust (the Appeal Tribunal).
   4. 4.4. The Appeal Tribunal shall conduct a review of the Initial Benefit Determination, and such review shall be based on evidence the Member provides as noted in Section 3.2; the evidence may or may not be of a medical nature and is wholly at the discretion of the Member to provide.
   5. 4.5. During the Review:
      1. 4.5.1. No deference will be given to the Initial Benefit Determination; and
      2. 4.5.2. The Appeal Tribunal shall have the discretion to interpret the Plan.
   6. 4.6. When the review is complete, the Trustee shall, in its sole discretion, make a decision regarding the outcome of the review, will notify the Member of its decision and may, if so required, issue a revised Notice of Entitlement.
   7. 4.7. If the appeal is denied, in whole or in part, the Member will be informed of the specific reason(s) for the denial and a reference to the specific API Plan Rule or point of law or decision point on which the decision is based.
   8. 4.8. If the Member does not agree with the outcome of the review, the Member may request a review under Stage 2 of this process. In such instances, the Trustee shall have the sole discretion to allow or deny such appeal.
2. THE APPEAL PROCESS – STAGE 2 – AEROMEDICAL ADVISORS ASSESSMENT.
   1. 5.1. The Member shall, at his or her own cost, choose an Aeromedical Advisor and notify the
      
      Trustee of the details of the chosen Aeromedical Advisor in writing.
   2. 5.2. The Trustee shall choose an Aeromedical Advisor and notify the Member of the details of the chosen Aeromedical Advisor in writing.
   3. 5.3. Both Aeromedical Advisors shall form a panel and review:

5.3.1. the Member’s records;

1. 5.3.2. Medical Certificate Revocation Documents;
2. 5.3.3. the findings of the medical panel of the GCAA (or other respective regulatory body) (as applicable);
3. 5.3.4. the API Plan Rules; and
4. 5.3.5. if necessary, examine the Member.

The Aeromedical Advisors may consult with licensed, board-certified medical specialists trained in the medical field in question if they encounter queries or specific medical or technical terms beyond the scope of their usual expertise.

1. 5.4. Each Aeromedical Adviser shall draft a report of their assessments, following which they will arrange a mutually convenient time to discuss their respective reports and produce a joint report containing their joint and/or respective recommendations.
2. 5.5. If the two Aeromedical Advisors come to an agreement:
   1. 5.5.1. they will send the joint report to the Member and to the Trustee;
   2. 5.5.2. the Trustee will consider the joint report and use its discretion to decide the outcome of the appeal;
   3. 5.5.3. the Trustee will notify the Member of its decision; and
   4. 5.5.4. if so required, issue an amended or new Notice of Entitlement.

6. THE APPEAL PROCESS – STAGE 3 – AEROMEDICAL ARBITRATOR ASSESMENT

1. 6.1. If the two Aeromedical Advisors are unable to agree, they will mutually agree upon a suitably qualified Aeromedical Arbitrator.
2. 6.2. The Member and the Trustee shall execute any agreements as may be necessary to implement the arbitration process.
3. 6.3. The Aeromedical Arbitrator will examine:
   1. 6.3.1. the joint and individual reports of the Aeromedical Advisors;
   2. 6.3.2. all Medical Certificate Revocation Documents;
   3. 6.3.3. the findings of the medical panel of the GCAA (or other respective regulatory body) (as applicable);
   4. 6.3.4. the API Plan Rules;
   5. 6.3.5. any other relevant information pertinent to the claim, including the reports submitted by the two Aeromedical Advisors; and
   6. 6.3.6. if necessary, shall examine the Member.
4. 6.4. The Aeromedical Arbitrator may also, if necessary, meet with the two Aeromedical Advisors ata mutually acceptable time and place to formulate their final opinion regarding the Member’sdisability and compliance with the benefit conditions and eligibility under the API Plan

Rules. This meeting may be held by means of a remote electronic communication system, including video or telephone conferencing technology or the Internet, or any combination.

1. 6.5. The Aeromedical Arbitrator may also consult with licensed, board-certified medical specialists trained in the medical field in question if they encounter queries or specific medical or technical terms beyond the scope of their usual expertise.
2. 6.6. The Aeromedical Arbitrator may also consult with the Trustee if they require clarification regarding the wording of the API Plan Rules.
3. 6.7. Following a thorough assessment, the Aeromedical Arbitrator shall submit the final opinion in writing to the Member and to the Trustee.
4. 6.8. The Member and the Trustee shall be bound by and shall implement such final opinion of the Aeromedical Arbitrator, and if required the Trustee shall issue a revised Notice of Entitlement.
5. 6.9. Aeromedical Arbitrator Compensation: When the Aeromedical Advisors select an Aeromedical Arbitrator, the Aeromedical Arbitrator will submit an estimate of the fees of such evaluation to the Member and to the Trustee prior to any information being disclosed to him / her. Thereafter:
   1. 6.9.1. API and the Member will each post with an escrow agent nominated by the Trustee,an amount equal to half (1/2) of the Aeromedical Arbitrator’s fee.
   2. 6.9.2. If the final opinion of the Aeromedical Arbitrator is in favor of the Member, the Trustee shall pay the total cost of both Aeromedical Advisers and the Aeromedical Arbitrator’s fee and the Member’s portion of the funds in escrow will be released back to theMember.
   3. 6.9.3. If the final opinion is in favor of the Trustee, the Trustee shall pay half (1/2) of the cost of the Aeromedical Arbitrator. The Member will pay half (1/2) the cost of the Aeromedical Arbitrator; the total cost of the Aeromedical Arbitrator will be paid from the funds placed in escrow. The Trustee or the Member may request additional time to post funds in escrow but in no event, such funds shall be posted no later than 30 days from the date notified and no final opinion will be given by the Aeromedical Arbitrator until such funds have been placed in escrow.

7. THE RULES OF THE PLAN AND MEMBER ACCEPTANCE.

1. 7.1. The current version of the API Plan Rules posted on the API website (as may be amended from time to time) shall be the valid controlling version. By virtue of the Member applying to become a member of API, the Member accepts and acknowledges that the API Plan Rules shall govern any decision regarding benefits.
2. 7.2. This appeal process is a part of the API Rules.
3. 7.3. In accepting the API Plan Rules, the Member agrees that the decision of the Trustee (or the Aeromedical Advisors or Aeromedical Arbitrator (where applicable)) reached as a result of the appeal process detailed herein with regard to his/her claim shall be final and binding, and the Member shall have no right to contest such decision(s) except as set forth below. The Member further acknowledges and agrees that the appeal process described herein is the sole and exclusive recourse for any and all controversies or claims arising out of or in connection with the API Plan and the Member expressly waives his / her right to file court actions disputing the decision of the appeal process except to enforce the appeal process and/or its legally binding decision except as set forth below.

8. APPEALING THE DECISION OF THE TRUSTEE FOLLOWING THE APPEAL PROCESS ALLOWED IN CERTAIN CIRCUMSTANCES.

8.1. In the event the Member is not satisfied with the decision of the Trustee, he / she may contest the decision before a competent court of Guernsey, based solely on the following grounds:

1. 8.1.1. The Aeromedical Arbitrator failed to address the relevant Medical Certificate Revocation Documents and / or other relevant information pertinent to the claim, including the reports submitted by the two Aeromedical Advisors in reaching their decision. For clarity, in addressing the relevant Medical Certificate Revocation Documents and / or any other relevant information pertinent to the claim, the Aeromedical Arbitrator fulfills the obligation by considering the same regardless of the final opinion forwarded to the Trustee; or
2. 8.1.2. There was a misapplication of relevant law or procedure by the Trustee and it can be demonstrated that the decision of the Trustee was arbitrary, capricious or failed to address the final opinion of the Aeromedical Arbitrator.

9. DEFINITIONS:
Aeromedical Advisor means a physician who is a licensed specialist, certified in aviation or

aerospace medicine. The Member and API may each select an Aeromedical Advisor.

Aeromedical Arbitrator means an independent physician who is a licensed specialist, certified in aviation or aerospace medicine and suitably qualified in aeronautical and medical arbitration, whose selection is mutually agreed upon by the Aeromedical Advisors.

Air Carrier shall have the meaning prescribed to it in the API Plan Rules.

API Plan Rules means the current version of the rules of the API Plan posted on the API website, asmay be amended from time to time (each individual provision a “Plan Rule”). For the avoidance of doubt the current version of the API Plan Rules on the date that a benefit claim is filed shall be the controlling version for the claim.

Initial Benefit Determination means the decision of the Trustee contained in a Notice of Entitlement to deny benefits to any one member or to award any Member a reduced benefit entitlement. SuchInitial Benefit Determination is based upon the recommendation of the Trustee’s Medical Advisor, the API Plan Rules, and shall be consistent with the applicable laws of the Island of Guernsey and the regulations set forth by the Guernsey Financial Services Commission.

Medical Certificate Revocation Documents means the medical documents and interviews submitted by the appropriate Air Carrier and medical service provider(s) contracted by the GCAA
or other respective regulatory body.

Notice of Entitlement shall have the meaning prescribed to it in the API Plan Rules.
Revocation Date means the date of the revocation of the Class I Medical Certificate by the GCAA or

other respective regulatory body.

Trustee means Sovereign Trust (Guernsey) Limited as Trustee of the Aircrew Protection International Trust.

Trustee’s Medical Advisor means the medical service provider(s) whose recommendation the Trustee considers when making the Initial Benefit Determination.