Attachment D - LTD open and closed paid claim summary.pdf
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- Solicitation number
- 120084 O5
- Issued by
- Lancaster County, Nebraska
About this file
This document is a paid claims summary report for a long-term disability (LTD) program provided by the State of Nebraska. The report details paid claims from July 2019 through January 2024, covering a group policy for the State of Nebraska (Subgroup 1002). The report includes information on the claim beneficiary, date of birth, claim status, benefit amount, initial payment date, and latest payment date. It covers a total of 68 claims with a group total of $1,092,143.50 in paid benefits.
The report provides detailed breakdowns of claims by month and year, including the number of open, closed, suspended, and in-process claims. Key details such as gender, claim type, and payment amounts are also included. Overall, this report summarizes the LTD claims activity and expenditures for the State of Nebraska's group long-term disability program over the covered period.
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Gender Status * M Open
F Closed
M Closed
F Open
F Closed
F Open
F Closed
F Open
F Closed
M Closed
M Closed
M Open
F Closed
STATE OF NEBRASKA Group Effective Date: 07/01/2019 Subgroup: 1002 - STATE OF NEBRASKA
LTD LTD
FACETS
Selection Parameters Values on Report
306147 00306147 - STATE OF NEBRASKA
ALL 1002
07/01/2019 to 10/24/2024 07/12/2019 to 01/15/2024
01/28/2021 12/28/2023 $19,596.00
July 2019 Incurred Total: $19,596.00
200782174 Long Term Disability 12/31/1958 07/12/2019
01/25/2021 12/28/2020 $4,506.06
200783340 Long Term Disability 06/04/1957 08/24/2019 01/09/2023 12/09/2022 $7,860.55
200781720 Long Term Disability 05/04/1960 08/08/2019
$12,366.61
200778307 Long Term Disability 12/13/1967 09/10/2019 01/28/2022 12/28/2023 $26,546.80
August 2019 Incurred Total:
$26,546.80
200784398 Long Term Disability 08/25/1952 10/23/2019 01/13/2021 12/09/2020 $19,322.64
September 2019 Incurred Total:
$19,322.64
200778068 Long Term Disability 01/22/1972 11/16/2019 01/03/2022 12/05/2022 $23,724.39
October 2019 Incurred Total:
01/15/2021 12/16/2020 $13,110.72
November 2019 Incurred Total: $36,835.11
200782331 Long Term Disability 10/27/1964 11/28/2019
01/25/2021 12/28/2020 $5,200.00
200793079 Long Term Disability 01/03/1967 12/19/2019 01/12/2021 12/11/2020 $24,531.21
200783341 Long Term Disability 04/26/1967 12/08/2019
$29,731.21
200788949 Long Term Disability 09/22/1957 01/09/2020 01/29/2021 12/29/2023 $4,443.33
December 2019 Incurred Total:
08/10/2020 10/12/2020 $6,862.44
January 2020 Incurred Total: $11,305.77
200786927 Long Term Disability 02/11/1964 01/21/2020
01/19/2021 12/21/2023 $4,900.00
202010934 Long Term Disability 02/28/1959 03/07/2020 01/25/2021 12/23/2020 $2,592.18
202004716 Long Term Disability 12/21/1969 03/03/2020
Incurred DateDate of BirthBenefitClaim Net Benefit AmountLatest Payment DateInitial Payment Date
Run Date: 10/25/2024 2:44:00 PM
* Claim Status Descriptions:
Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:
Attachment D
LTD LTD
FACETS
Selection Parameters Values on Report
306147 00306147 - STATE OF NEBRASKA
ALL 1002
07/01/2019 to 10/24/2024 07/12/2019 to 01/15/2024
M Open
F Closed
F Closed
F Closed
F Closed
F Open
F Open
M Open
F Closed
F Closed
F Closed
M Closed
M Open
M Open
M Closed
F Closed
01/21/2021 12/21/2023 $97,996.08
March 2020 Incurred Total: $105,488.26
200788928 Long Term Disability 02/21/1961 03/13/2020
06/17/2021 07/29/2021 $7,113.04
June 2020 Incurred Total: $7,113.04
202104192 Long Term Disability 07/10/1952 06/24/2020
01/27/2021 08/27/2021 $8,103.33
July 2020 Incurred Total: $8,103.33
202006051 Long Term Disability 02/11/1961 07/11/2020
02/17/2021 03/31/2021 $11,704.20
202106539 Long Term Disability 10/15/1961 08/07/2020 01/23/2023 12/23/2022 $8,399.00
202012903 Long Term Disability 10/20/1957 08/01/2020
01/03/2022 12/21/2022 $24,643.09
August 2020 Incurred Total: $44,746.29
202102594 Long Term Disability 09/24/1969 08/18/2020
01/02/2023 12/04/2023 $29,803.87
202100993 Long Term Disability 12/18/1981 09/18/2020 01/01/2024 12/30/2022 $10,492.00
202018738 Long Term Disability 01/09/1964 09/14/2020
01/17/2023 12/18/2023 $17,949.20
September 2020 Incurred Total: $58,245.07
202112009 Long Term Disability 07/15/1972 09/28/2020
03/23/2022 04/29/2021 $6,861.74
202133629 Long Term Disability 03/01/1958 10/07/2020 10/27/2021 10/27/2021 $732.25
202111764 Long Term Disability 12/20/1993 10/05/2020
$7,593.99
202331662 Long Term Disability 10/08/1962 11/05/2020 01/24/2023 12/27/2022 $10,642.94
October 2020 Incurred Total:
01/04/2022 12/06/2021 $22,254.70
November 2020 Incurred Total: $32,897.64
202118903 Long Term Disability 01/07/1969 11/16/2020
01/04/2022 12/23/2022 $26,890.00
December 2020 Incurred Total: $26,890.00
202115743 Long Term Disability 03/20/1958 12/17/2020
12/14/2021 12/21/2021 $7,266.86
202147526 Long Term Disability 09/06/1951 01/22/2021 01/10/2022 12/09/2021 $12,097.09
202141672 Long Term Disability 09/16/1970 01/06/2021
Run Date: 10/25/2024 2:44:00 PM
* Claim Status Descriptions:
Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:
Selection Parameters Values on Report
306147 00306147 - STATE OF NEBRASKA
ALL 1002
07/01/2019 to 10/24/2024 07/12/2019 to 01/15/2024
F Open
F Open
M Suspend
M Closed
M Closed
M Open
M Open
M Open
M Closed
F Open
F Closed
F Open
F Open
$19,363.95
202140608 Long Term Disability 03/21/1968 02/01/2021 01/20/2022 12/22/2021 $7,587.25
January 2021 Incurred Total:
01/01/2024 12/01/2023 $6,151.19
February 2021 Incurred Total: $13,738.44
202128637 Long Term Disability 01/31/1969 02/13/2021
01/09/2023 12/08/2022 $5,289.91
March 2021 Incurred Total: $5,289.91
202142103 Long Term Disability 01/13/1963 03/23/2021
01/06/2022 04/13/2022 $5,602.04
May 2021 Incurred Total: $5,602.04
202154028 Long Term Disability 11/20/1969 05/18/2021
02/08/2022 07/14/2022 $7,636.16
July 2021 Incurred Total: $7,636.16
202210543 Long Term Disability 10/09/1961 07/09/2021
01/27/2023 12/27/2023 $48,524.78
October 2021 Incurred Total: $48,524.78
202191984 Long Term Disability 11/16/1967 10/09/2021
01/06/2023 12/06/2023 $29,740.47
November 2021 Incurred Total: $29,740.47
202335859 Long Term Disability 04/28/1976 11/18/2021
01/26/2024 12/29/2022 $26,118.65
202433703 Long Term Disability 02/18/1972 01/12/2022 01/02/2023 12/08/2022 $1,823.33
202410722 Long Term Disability 05/03/1965 01/07/2022
$27,941.98
202389855 Long Term Disability 07/27/1960 02/23/2022 01/11/2023 12/12/2022 $16,790.64
January 2022 Incurred Total:
$16,790.64
202345906 Long Term Disability 04/28/1947 04/19/2022 04/28/2023 12/05/2022 $15,099.65
February 2022 Incurred Total:
$15,099.65
202502003 Long Term Disability 09/07/1972 05/18/2022 01/03/2024 12/04/2023 $46,351.15
April 2022 Incurred Total:
$46,351.15
202536681 Long Term Disability 02/22/1983 06/03/2022 01/22/2024 12/19/2023 $43,122.05
May 2022 Incurred Total:
Run Date: 10/25/2024 2:44:00 PM
Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:
Selection Parameters Values on Report
306147 00306147 - STATE OF NEBRASKA
ALL 1002
07/01/2019 to 10/24/2024 07/12/2019 to 01/15/2024
M Closed
F Open
M Closed
F Open
M Open
M Open
M Open
F Closed
F Open
M Closed
F Open
M Closed
M Open
F Open
02/08/2023 02/08/2023 $2,127.10
June 2022 Incurred Total: $45,249.15
202568968 Long Term Disability 01/06/1988 06/27/2022
01/11/2024 12/11/2023 $59,067.47
July 2022 Incurred Total: $59,067.47
202561694 Long Term Disability 07/30/1970 07/26/2022
05/10/2024 12/18/2023 $53,878.47
202537124 Long Term Disability 09/16/1982 08/11/2022 01/19/2024 12/05/2023 $15,159.45
202786073 Long Term Disability 02/28/1967 08/02/2022
01/02/2024 08/07/2023 $7,470.71
August 2022 Incurred Total: $76,508.63
202569193 Long Term Disability 10/22/1967 08/12/2022
01/16/2024 12/15/2023 $33,334.93
202509351 Long Term Disability 02/19/1980 10/25/2022 01/12/2024 12/12/2023 $1,800.00
202856927 Long Term Disability 12/30/1964 10/24/2022
06/07/2023 08/15/2023 $7,044.90
October 2022 Incurred Total: $42,179.83
202690681 Long Term Disability 05/12/1968 10/28/2022
01/17/2024 12/18/2023 $30,792.55
November 2022 Incurred Total: $30,792.55
202712244 Long Term Disability 12/11/1979 11/29/2022
01/26/2024 12/26/2023 $1,100.00
December 2022 Incurred Total: $1,100.00
202816802 Long Term Disability 06/07/1973 12/08/2022
01/16/2024 12/15/2023 $73,953.75
February 2023 Incurred Total: $73,953.75
202824545 Long Term Disability 04/28/1970 02/27/2023
03/01/2024 05/06/2024 $2,253.13
March 2023 Incurred Total: $2,253.13
202936804 Long Term Disability 12/04/1973 03/30/2023
01/02/2024 12/04/2023 $10,219.63
April 2023 Incurred Total: $10,219.63
202814625 Long Term Disability 05/31/1959 04/16/2023
01/19/2024 10/23/2024 $20,950.64
May 2023 Incurred Total: $20,950.64
202905759 Long Term Disability 01/04/1977 05/20/2023
Run Date: 10/25/2024 2:44:00 PM
Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:
Selection Parameters Values on Report
306147 00306147 - STATE OF NEBRASKA
ALL 1002
07/01/2019 to 10/24/2024 07/12/2019 to 01/15/2024
M Open
F Open
M Open
F Closed
01/23/2024 09/25/2024 $8,564.25
June 2023 Incurred Total: $8,564.25
202972032 Long Term Disability 01/17/1961 06/09/2023
04/01/2024 10/02/2024 $22,996.53
203041534 Long Term Disability 04/22/1971 09/28/2023 05/15/2024 09/16/2024 $12,530.38
203036393 Long Term Disability 09/29/1978 09/12/2023
203382453 Long Term Disability 09/08/1986 01/15/2024 08/13/2024 09/20/2024 $2,916.63
September 2023 Incurred Total:
Group Total: $1,092,143.50
$2,916.63
Subgroup 00001002 Total: $1,092,143.50
January 2024 Incurred Total:
$35,526.91
Run Date: 10/25/2024 2:44:00 PM
Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:
Paid Claim Summary by Incurred Date Selection Parameters Values on Report
Group/Customer: 306147 00306147 - STATE OF NEBRASKA
Subgroup/Policy: ALL 1002
Incurred Date Range: 07/01/2019 to 10/24/2024 07/12/2019 to 01/15/2024
Business Segment: LTD LTD
Source System: FACETS
STATE OF NEBRASKA
All Subgroups by Product Net Benefit Amount
Long Term Disability $1,092,143.50
All Subgroups by Product Total $1,092,143.50
Run Date: 10/25/2024 2:44:00 PM
Appealed: Claim has been disputed | Closed: Claim is closed | In Process: Claim is in adjudication process | Incomplete:
Gender Date of Birth
Status * F 05/04/1960 Closed
M 06/04/1957 Closed
F 08/25/1952 Closed
F 10/27/1964 Closed
F 01/03/1967 Closed
M 09/22/1957 Closed
M 02/11/1964 Closed
F 02/28/1959 Closed
F 07/10/1952 Closed
F 02/11/1961 Closed
F 10/20/1957 Closed
F 10/15/1961 Closed
F 07/15/1972 Closed
F 12/20/1993 Closed
F 03/01/1958 Closed
M 10/08/1962 Closed
M 09/16/1970 Closed
F 09/06/1951 Closed
M 11/20/1969 Closed
M 10/09/1961 Closed
M 02/18/1972 Closed
F 04/28/1947 Closed
M 01/06/1988 Closed
M 02/28/1967 Closed
F 05/12/1968 Closed
M 06/07/1973 Closed
M 12/04/1973 Closed
F 09/08/1986 Closed
Claim Benefit Incurred Date Initial Payment Date Latest Payment Date Net Benefit Amount
200783340 Long Term Disability 08/24/2019 01/09/2023 12/09/2022 $7,860.55
200781720 Long Term Disability 08/08/2019 01/25/2021 12/28/2020 $4,506.06
200782331 Long Term Disability 11/28/2019 01/15/2021 12/16/2020 $13,110.72
200784398 Long Term Disability 10/23/2019 01/13/2021 12/09/2020 $19,322.64
200788949 Long Term Disability 01/09/2020 01/29/2021 12/29/2023 $4,443.33
200793079 Long Term Disability 12/19/2019 01/12/2021 12/11/2020 $24,531.21
202010934 Long Term Disability 03/07/2020 01/25/2021 12/23/2020 $2,592.18
200786927 Long Term Disability 01/21/2020 08/10/2020 10/12/2020 $6,862.44
202006051 Long Term Disability 07/11/2020 01/27/2021 08/27/2021 $8,103.33
202104192 Long Term Disability 06/24/2020 06/17/2021 07/29/2021 $7,113.04
202106539 Long Term Disability 08/07/2020 01/23/2023 12/23/2022 $8,399.00
202012903 Long Term Disability 08/01/2020 02/17/2021 03/31/2021 $11,704.20
202111764 Long Term Disability 10/05/2020 03/23/2022 04/29/2021 $6,861.74
202112009 Long Term Disability 09/28/2020 01/17/2023 12/18/2023 $17,949.20
202331662 Long Term Disability 11/05/2020 01/24/2023 12/27/2022 $10,642.94
202133629 Long Term Disability 10/07/2020 10/27/2021 10/27/2021 $732.25
202147526 Long Term Disability 01/22/2021 01/10/2022 12/09/2021 $12,097.09
202141672 Long Term Disability 01/06/2021 12/14/2021 12/21/2021 $7,266.86
202210543 Long Term Disability 07/09/2021 02/08/2022 07/14/2022 $7,636.16
202154028 Long Term Disability 05/18/2021 01/06/2022 04/13/2022 $5,602.04
202345906 Long Term Disability 04/19/2022 04/28/2023 12/05/2022 $15,099.65
202433703 Long Term Disability 01/12/2022 01/02/2023 12/08/2022 $1,823.33
202786073 Long Term Disability 08/02/2022 05/10/2024 12/18/2023 $53,878.47
202568968 Long Term Disability 06/27/2022 02/08/2023 02/08/2023 $2,127.10
202816802 Long Term Disability 12/08/2022 01/26/2024 12/26/2023 $1,100.00
202690681 Long Term Disability 10/28/2022 06/07/2023 08/15/2023 $7,044.90
203382453 Long Term Disability 01/15/2024 08/13/2024 09/20/2024 $2,916.63
202936804 Long Term Disability 03/30/2023 03/01/2024 05/06/2024 $2,253.13
Gender Date of Birth Status * M 12/31/1958 Open
F 12/13/1967 Open
F 01/22/1972 Open
F 04/26/1967 Open
M 12/21/1969 Open
M 02/21/1961 Open
F 09/24/1969 Open
F 01/09/1964 Open
M 12/18/1981 Open
M 01/07/1969 Open
M 03/20/1958 Open
F 03/21/1968 Open
F 01/31/1969 Open
M 11/16/1967 Open
M 04/28/1976 Open
M 05/03/1965 Open
F 07/27/1960 Open
F 09/07/1972 Open
F 02/22/1983 Open
F 07/30/1970 Open
F 09/16/1982 Open
M 10/22/1967 Open
M 12/30/1964 Open
M 02/19/1980 Open
F 12/11/1979 Open
F 04/28/1970 Open
M 05/31/1959 Open
F 01/04/1977 Open
M 01/17/1961 Open
F 09/29/1978 Open
M 04/22/1971 Open
200782174 Long Term Disability 07/12/2019 01/28/2021 12/28/2023 $19,596.00 Claim Benefit Incurred Date Initial Payment Date Latest Payment Date Net Benefit Amount
200778068 Long Term Disability 11/16/2019 01/03/2022 12/05/2022 $23,724.39
200778307 Long Term Disability 09/10/2019 01/28/2022 12/28/2023 $26,546.80
202004716 Long Term Disability 03/03/2020 01/19/2021 12/21/2023 $4,900.00
200783341 Long Term Disability 12/08/2019 01/25/2021 12/28/2020 $5,200.00
202102594 Long Term Disability 08/18/2020 01/03/2022 12/21/2022 $24,643.09
200788928 Long Term Disability 03/13/2020 01/21/2021 12/21/2023 $97,996.08
202100993 Long Term Disability 09/18/2020 01/01/2024 12/30/2022 $10,492.00
202018738 Long Term Disability 09/14/2020 01/02/2023 12/04/2023 $29,803.87
202115743 Long Term Disability 12/17/2020 01/04/2022 12/23/2022 $26,890.00
202118903 Long Term Disability 11/16/2020 01/04/2022 12/06/2021 $22,254.70
202128637 Long Term Disability 02/13/2021 01/01/2024 12/01/2023 $6,151.19
202140608 Long Term Disability 02/01/2021 01/20/2022 12/22/2021 $7,587.25
202335859 Long Term Disability 11/18/2021 01/06/2023 12/06/2023 $29,740.47
202191984 Long Term Disability 10/09/2021 01/27/2023 12/27/2023 $48,524.78
202389855 Long Term Disability 02/23/2022 01/11/2023 12/12/2022 $16,790.64
202410722 Long Term Disability 01/07/2022 01/26/2024 12/29/2022 $26,118.65
202536681 Long Term Disability 06/03/2022 01/22/2024 12/19/2023 $43,122.05
202502003 Long Term Disability 05/18/2022 01/03/2024 12/04/2023 $46,351.15
202537124 Long Term Disability 08/11/2022 01/19/2024 12/05/2023 $15,159.45
202561694 Long Term Disability 07/26/2022 01/11/2024 12/11/2023 $59,067.47
202856927 Long Term Disability 10/24/2022 01/16/2024 12/15/2023 $33,334.93
202569193 Long Term Disability 08/12/2022 01/02/2024 08/07/2023 $7,470.71
202712244 Long Term Disability 11/29/2022 01/17/2024 12/18/2023 $30,792.55
202509351 Long Term Disability 10/25/2022 01/12/2024 12/12/2023 $1,800.00
202814625 Long Term Disability 04/16/2023 01/02/2024 12/04/2023 $10,219.63
202824545 Long Term Disability 02/27/2023 01/16/2024 12/15/2023 $73,953.75
202972032 Long Term Disability 06/09/2023 01/23/2024 09/25/2024 $8,564.25
202905759 Long Term Disability 05/20/2023 01/19/2024 10/23/2024 $20,950.64
203041534 Long Term Disability 09/28/2023 05/15/2024 09/16/2024 $12,530.38
203036393 Long Term Disability 09/12/2023 04/01/2024 10/02/2024 $22,996.53
| Sheet1 |
| Sheet2 |
| LTD CLOSED |
| LTD OPEN |
File details come from the government source that posted it. Updated .