Disability Claim Analysis & Determination Framework
Systematize disability claim analysis with evidence extraction and policy application
What You Can Do
You can analyze disability claims methodically by extracting key evidence, cross-referencing claimant statements against medical records to identify inconsistencies, mapping circumstances to policy criteria, and generating defensible determinations with clear rationale. This skill reduces analysis time, improves consistency across claims, and creates audit-ready documentation that withstands review and appeals.
Features
Automatically identifies and categorizes relevant facts from claim documents, medical records, and employment history into evidence buckets (medical findings, work capacity, functional limitations, timeline gaps).
Flags contradictions between claimant statements, medical provider notes, and employment records with specific citations, highlighting red flags for further investigation.
Maps claimant circumstances directly to policy definitions and eligibility thresholds, showing which criteria are met, partially met, or unmet with evidence citations.
Produces clear approval or denial decisions with documented rationale, supporting each conclusion with extracted evidence and policy application.
Generates determination letters and analysis summaries formatted for compliance review, appeals, and legal scrutiny with complete decision trails.
Identifies high-risk claims requiring escalation (missing evidence, extreme inconsistencies, medical complexity, potential fraud patterns).
Visualizes medical history, treatment gaps, functional decline patterns, and employment transitions to assess claim credibility and evolution.
Example Output
Evidence Summary for Claim #DIS-2024-0891:
- Medical findings: Lumbar fusion (2022), ongoing physical therapy, imaging shows degenerative disc disease
- Claimant statement: "Cannot lift more than 5 lbs, frequent severe pain"
- Work history: Warehouse lead (requires heavy lifting) → unemployed 8 months → desk job attempt (3 weeks)
- Inconsistency flagged: Medical records show "therapeutic exercise tolerance" but claimant reports inability to perform any lifting
Policy Criteria Assessment:
- Meets: Severe medical condition (yes), Duration >12 months (yes)
- Partially meets: Functional impairment (conflicting evidence)
- Unmet: No recent vocational assessment
Determination: PENDING — Request updated FCE (Functional Capacity Evaluation) to resolve medical/functional inconsistency before final approval
What's Included
- Evidence Categorization Framework: Structured templates for organizing medical, employment, financial, and functional evidence with consistent taxonomy.
- Policy Criteria Checklist: Mapping guides that align claim facts to federal/state policy thresholds (severity, duration, work capacity, medical certainty).
- Inconsistency Detection Rules: Heuristics for identifying contradictions between statements, medical records, and third-party reports with severity weighting.
- Determination Letter Templates: Customizable formats for approval, denial, and pending decisions with sections for evidence summary, policy application, and appeal rights.
- Risk Assessment Matrix: Scoring methodology for flagging claims that require supervisor review, investigation, or escalation based on inconsistency patterns.
Who It's For
- Disability Claims Adjudicators
- Medical Reviewers & Examiners
- Disability Program Managers
- Claims Supervisors & Quality Reviewers
- Policy Analysts & Compliance Officers
Best For
- Initial claim eligibility assessment
- Medical evidence evaluation and inconsistency investigation
- Determination documentation and letter generation
- Claims quality audits and consistency reviews
- Appeals preparation and defense documentation
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