How it works
From claim file to a record that stands
Follow how a claim file moves through the review: from the moment it arrives to a documented, lawyer-signed recommendation on the administrative record.
01 · The standard
Deference only follows the record
Courts defer to a plan administrator's decision as long as the administrative record shows a reasoned, consistent process. That protection is earned file by file. Where the record is thin, or the reasoning was assembled after the fact, deference gives way and the file itself becomes the exhibit.
At scale, that is the exposure. Quality assurance samples a fraction of the book, and the files outside the sample carry whatever record they happen to have.
02 · What gets examined
Consistency, documented at the time
Whether the question comes from an examiner, an appeal, or discovery, it is the same question: were decisions reasoned consistently, and was the reasoning documented when the decision was made, not reconstructed afterward.
LTD claim files
Long, medically complex, often running to hundreds of pages. The reasoning has to hold up years later.
Appeals & reviews
The appeal is decided on the administrative record. What is not in the file at decision time is not there later.
Regulator examinations
Examiners look across the book for consistency. The answer has to come from the files, not from memory.
Litigation & discovery
The whole file is produced: what was reviewed, what was not, and how the reasoning compares to similar claims.
03 · How the review works
Every claim file read end-to-end. A lawyer signs.
A claim file arrives
Any length, at any stage. An LTD file can run to hundreds of pages; every one of them is in scope.
Every page is read
The system reads the file end-to-end, not a sample of it. The timeline is structured and the findings are set against the plan terms.
Contradictions are flagged
Anything that does not line up is surfaced: dates that conflict, a report that contradicts a statement, terms applied differently from similar claims.
The recommendation is drafted
A reasoned recommendation, consistent with how similar claims were handled, written to be read later.
A lawyer reviews and signs
Nothing returns as machine output. A lawyer works through the file, the flags and the draft, and signs the recommendation.
The documented recommendation returns to your team
Signed, documented, and ready for the record. Your team finalizes the decision with the reasoning already in the file.
04 · What you get
A complete administrative record, lawyer-signed
Every claim decision is finalized with a lawyer-signed, documented recommendation already in the file. When an appeal is filed, an examiner asks, or discovery arrives, the record exists; nothing has to be reconstructed. Full review also finds what sampling cannot. For one of our clients, moving from sampled to full review surfaced 2% of decisions that had been wrongly approved, summing up to over $11M a year.
