Disability claims adjudication on a full file — the plan’s definition, element by element, with the evidence beside it
Examiners decide on a full file, not a half-gathered one.
See one case, screen by screen ↓Software that helps a disability claim examiner decide a short- or long-term disability claim: gather the medical, job and employer evidence, compare it to the plan’s definition of disability, and write the decision letter. Disability Claims Adjudication adds seven agents that gather and read the file and lay the definition out as elements, so the examiner decides each one with the evidence beside it.
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A short- or long-term disability decision turns on one question: does the medical evidence show the claimant cannot do what the plan says they must be unable to do? Answering it takes the claim form, the employer statement, the attending physician statement, office notes, imaging, a job description and payroll — from five different parties — read side by side against the certificate.
Most of the examiner’s time goes on chasing and reading those documents, and missing items are found late because nobody lays the file against the plan until it is “complete”. Reasons written from memory are inconsistent and hard to defend on appeal, and the any-occupation review at month 24 starts the vocational work from scratch, years later.
Estimated split of an examiner’s working time on a typical LTD claim, by hand and with the solution. Time spent waiting for doctors and employers to answer is not counted.
Seven agents gather and read the file and draw the job against the restrictions; the examiner decides each element.
Calvin Odum, 52, an industrial maintenance technician at Brookmere Foods in Dayton, had an L4-5 microdiscectomy on 16 September. His long-term disability claim, LTD-26-04412, is on day 34 of 45. Here is how it is decided, screen by screen, in the working solution.
Renata carries 128 open claims; 24 have an initial decision due in the next 30 days. Each row shows the condition, the day of 45, the elements decided and the next action. Owen Takahashi’s long-COVID claim is on day 41 and needs a 30-day extension notice by Fri 16 Oct. Calvin Odum’s is ready to decide.
“Agents read every new document overnight; the next action is theirs or yours.”
The claim opens on Decide. The definition of disability from certificate GLTD-58210, page 14, is laid out as one sentence broken into six elements: sickness or injury, regular care of a physician, the 90-day elimination period, own occupation, a 20% loss of indexed monthly earnings, and not excluded. The agents read five as met; element 4, own occupation, is marked “not able · decide”.
The evidence checklist shows 14 of 14 required documents in, 61 pages — each with the element it is needed for, when it was requested and when it arrived. Dr. Sethi’s APS was asked for on 8 Sep, chased on 22 Sep and arrived on 5 Oct. One follow-up is still open: post-operative physical therapy notes from Valley Motion, asked for on 6 Oct.
“The file was complete on day 27; deciding today uses 34 of 45 days and needs no extension.”
The plan definition reader splits the certificate into six elements and finds the own-occupation period ends Tue 3 Oct 2028. The medical record reader puts 12 encounters on the timeline. The job demands analyst sets 8 demands from the 2024 physical demands analysis and flags one conflict: the 2025 job posting says “lift up to 75 lbs”. The benefit calculator arrives at $3,265.60 a month from Sun 4 Oct 2026.
“The 2024 physical demands analysis governs; either figure is above the 10 lb restriction.”
From the emergency visit on 5 Jul to the post-operative visit on 2 Oct, built from 9 documents. The lift limit and the stand/walk limit are drawn as step lines against his job’s 50 lb and 6 hours, and each restriction on file sits in a table with who wrote it and the page it is on. Re-evaluation is set for 13 Nov.
Renata confirms the five elements the agents read as met, each citing at least one page: the MRI for sickness or injury, the office notes for physician care, the STD claim summary for the elimination period, payroll for the earnings loss and the certificate for exclusions. Each is recorded in her name.
“5 elements confirmed met · element 4, own occupation, is yours to decide”
Any citation opens the page it rests on. Dr. Priyanka Sethi’s attending physician statement of 2 Oct, page 2: lift/carry “10 lbs occasionally; no frequent lifting”, stand/walk “20 minutes at a time, 2 hours total per day”, no ladders — with the lines the agents used highlighted.
Beneath the definition, each job demand is a bar and each restriction a red line. The lifting bar runs past the 10 lb line, and so do frequent lifting, standing, bending and ladders: 5 of 8 demands. Renata marks element 4 “not able”, and the chart is stamped “Own occupation: not able”.
“Element 4: not able · recorded with 2 sources” — the APS p.2 and the demands analysis p.2.
From Wed 4 Oct 2028 the plan pays only if Calvin cannot do any gainful occupation. Seven occupations that use his skills are tested against the same restrictions and a gainful wage of $18.84 an hour — 60% of his indexed earnings. Three stay open: maintenance planner/scheduler, maintenance records coordinator and work-order dispatcher. Security monitor fits but pays $16.90.
“3 of 7 open at today’s restrictions · the vocational consultant decides employability”
The letter drafter writes the approval from the six decided elements: $3,265.60 a month from October 4, the reasons in plain words, the restrictions and demands relied on, why no Social Security offset is taken, the right to copies, 180 days to appeal and the language notice. Renata signs and sends it.
“Signed and sent by Renata Voss on day 34 — 11 days before the deadline. First payment Wed 4 Nov.”
The same LTD claim, seen by the four people who carry it — what their week looked like, and what it looks like now.
Seven agents gather and read the file and draw the job against the restrictions; the examiner decides each element.
Builds the checklist each plan and claim type needs, requests what is missing from the treating physician, employer and claimant, and chases on day 7 and day 14.
Reads statements, notes, imaging and operative reports; builds the timeline and lifts every restriction with its page and author.
Sets each physical and mental demand of the job, with its amount and frequency, from the demands analysis, job description, employer statement and any posting.
Splits the certificate’s definition of disability into elements and reads the elimination period, earnings test, exclusions and the own/any occupation switch.
Finds occupations that use the claimant’s skills and tests each against the restrictions and the gainful wage.
Works out the gross benefit, offsets, start date and the end of the own-occupation period.
Drafts approvals, denials and extension notices with the plan provisions, every reason cited, and the rights to documents, appeal time and language notice.
Decides each element and signs. The agents propose; a named person decides.
Examiners ask in plain words — or tell it what to confirm. Every answer cites the page it rests on.
Why can’t Calvin Odum do his own occupation?
Because five of its eight physical demands are beyond Dr. Sethi’s restrictions of 2 October. The 2024 demands analysis puts the job at medium work: lifting 50 lb occasionally and 25 lb frequently, standing 6 hours, frequent bending and ladders. He is limited to 10 lb occasionally, no frequent lifting, 2 hours on his feet, and no ladders.
Which other jobs could he do at the any-occupation review?
At today’s restrictions, 3 of 7 occupations that use his skills stay open: maintenance planner/scheduler ($29.10 an hour), maintenance records coordinator ($24.60) and work-order dispatcher ($21.40) — all sedentary and above the gainful wage of $18.84. Security monitor fits his restrictions but pays $16.90, so it is not gainful. The vocational consultant makes that call in 2028.
What is holding up Owen Takahashi’s claim?
The restrictions. Dr. Lowery limits sitting to 4 hours and concentration to 3 hours a day, based on reported symptoms, with no testing. Neuropsychological testing is booked for 4 November, after the 45-day deadline of Fri 16 Oct. The notice for a 30-day extension is drafted; Joan Pelletier’s nurse review is due Wed 14 Oct.
Confirm the routine elements on Calvin’s claim
Done — 5 elements the agents read as met are confirmed, each with its sources: sickness or injury, physician care, the 90-day elimination period, the earnings loss and no exclusion. The decision is recorded in your name. Own occupation is left for you — it is the one that needs judgement.
13 screens from the working solution, on its sample data. Pick one to see it large.
Plan definitions are read from each certificate and confirmed by plan administration. Clocks, authority and routing are settings, and every change is versioned.
| Setting | Default | Choose from |
|---|---|---|
| Plan definitions per policy | 24 mo own occupation · 90 d elimination · 20% earnings loss · 60% gainful | Read from each certificate |
| Initial decision | 45 days | Two × 30-day extensions, with notice |
| Evidence follow-up | Day 7 and day 14 after each request | Your own follow-up practice |
| Examiner approves benefits up to | $8,000 a month | $4,000 to $15,000, in $500 steps |
| Every denial | Second review by the LTD claims manager | The named LTD claims manager |
| Refer to the nurse | When restrictions are missing, conflict, or rest only on reported symptoms | On · Off |
| Refer to the vocational consultant | When a job demand is within 20% of a restriction, and at every any-occupation review | On · Off |
| Demand sources, in order | Demands analysis › job description › employer statement › job posting | On · Off |
| Draft extension notices | On day 38 when evidence outside the plan’s control is still open | On · Off |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample claim data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (29 CFR 2560.503-1, the ERISA claims procedure — 45 days to decide a disability claim, two 30-day extensions; CDIA disability statistics, IBI 2024 — 26% of LTD claims are musculoskeletal). People, companies, plans and claims named on this page are fictional — characters and sample data in the working solution.
Software that helps a disability claim examiner decide a short- or long-term disability claim: gather the medical, job and employer evidence, compare it to the plan’s definition of disability, and write the decision letter. Disability Claims Adjudication adds seven agents that gather and read the file and lay the definition out as elements, so the examiner decides each one with the evidence beside it.
It does not — the examiner does. The job demands analyst sets each demand of the job from the employer’s documents, the medical record reader lifts each restriction from the doctor’s statement, and the two are drawn side by side so anyone can see which demands the restrictions rule out. In the hero claim, 5 of 8 demands exceed the restrictions; the examiner decides “not able”.
Yes. The caseload holds short- and long-term claims together, and each policy’s definition, elimination period, earnings test and benefit are read from its certificate — for example a 7-day elimination period on an STD plan and 90 days on an LTD plan.
Yes. The occupation matcher finds occupations that use the claimant’s skills and tests each against the same restrictions and the plan’s gainful wage, at the first decision rather than two years later. The vocational consultant decides employability and signs the study.
No. The letter drafter drafts and the examiner signs; denials need a second review by the claims manager. The benefit calculator works out the amount, offsets and dates but never pays, and no agent contacts a doctor beyond a standard request.
Every reason in the letter carries a citation to the document and page it rests on — the certificate, the APS, the demands analysis, payroll — and a checklist beside the letter shows what it must say, from plan provisions to appeal rights and the language notice.
Yes. The agents read and recommend; the examiner confirms or decides every element and signs the letter. Authority limits, second reviews, routing to the nurse and vocational consultant, and the claim clocks are all settings.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your group certificates, letter templates and a sample of past claim files — and it goes live once every quality gate has passed. We will walk you through it on your own claims first.
Any census layout quote-ready the day the RFP arrives, every change on the record.
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1-min demoWe’ll run Disability Claims Adjudication on a sample of your own STD and LTD claim files.