NU Online News Service, June 5, 12:56 p.m. EST

Adjusters using computerized-claims systems to evaluate claims payouts can manipulate the systems to substantially lower injury claim payments, according to a report by the Consumer Federation of America.

In the report titled “Low Ball: An Insider's Look at How Insurers Can Manipulate Computerized Systems to Broadly Underpay Injury Claims,” CFA Claims Project Director Mark Romano specifically calls out the Colossus claims system, sold by Computer Sciences Corporation (CSC).

Though the product is marketed to achieve consistency in claims handling, Romano says adjusters can manipulate claims payouts directly by tampering with Colossus' tuning system. Tuning the program allows the software to render a desired payment amount to particular types of injuries.

Romano says adjusters can reduce the tuning across the board by lowering a predetermined percentage amount, selectively removing or excluding higher-cost claims from the tuning sample, and lowering the average number of claims payments through a process called “dragging the trauma severity line” to keep payments calculated by the system down.

Adjusters can also indirectly manipulate Colossus through data entry, Romano says. He provides an example where insurance companies require adjusters with no medical credentials to “second guess” medical professionals and select a less-expensive injury code to input into the software.

In instances where a claimant needs further medical treatment, adjusters can select a “final prognosis” code, resulting in a lower payout that does not cover the additional care.

The report also cites excerpts from court records in Hensley v. Computer Sciences Corporation in which CSC executives admit to the claims made in the CFA report, Romano contends.

“CSC told insurers that they could produce huge reductions in claims payouts in their sales pitches, which insurers achieved in many cases,” says Robert Hunter, director of insurance at CFA, in a press conference. “CSC promised savings in many documents, but the use of the word 'savings' became controversial.”

According to Hunter, court documents “reveal that CSC decided to substitute the word 'consistency' for 'savings' out of concern for litigation.”

A call to CSC was not immediately returned.

According to Robert Detlefsen, vice president of public policy with the National Association of Mutual Insurance Companies (NAMIC), the report places a great deal of emphasis on the semantics of the words “savings” and “consistency” without examining the many meanings of the words.

“One could interpret 'savings' in this context as the amount an insurer would save by virtue of not over-paying claims—there is a lot of evidence that overpayment does in fact take place in this country,” says Detlefsen. “The assumption that's made [in the report] is that savings are made by under-paying.”

Detlefsen went on to say the report is “fatally flawed” for not acknowledging a legitimate purpose for Colossus to provide insurers with savings.

Special Reports /

CFA: Insurers Can Tamper with Computer Systems to Underpay Injury Claims

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