Hitch-Hikers guide to Claims Assessment LDG presentation Thursday 28 July 2011

Transcription

1 Hitch-Hikers guide to Claims Assessment LDG presentation Thursday 28 July 2011 Margaret Dennis - Technical Services Manager, Asteron Annette Veltman - Senior Claims Analyst, Asteron

2 What do you need to be to be a Claims assessor

3 A Doctor

4 A nurse

5 An investigator

6 Counsellor

7 A lawyer

8 Accountant

9 Rehab provider Psychologist Underwriter Product Manager Stakeholder Manager Mediator/ Complaints manager

10 Claims Assessment Assess Claims under all products Term Life (Death Claims), TPD (Total and Permanent Disablement), Trauma, Income Protection and GSC (Group Salary Continuance) under a wide range of current and legacy products. Different products, policies and principles applied to IP, GSC, TPD and Trauma claims, the basics of assessment and case management underpin all these products

11 IP and GSC- assess current situation and future management of the claim, within policy terms TPD- determine current and future liability Trauma- assess complex medical information and policy terms Death claims- manage legislative requirements within policy terms and cause of death. Grieving relatives.

12 We assess not process This is the key to successful claims and case management. Gather all necessary information and making a decision within the terms of the policy. It is not just processing a payment. Requires common sense. Each case is assessed on its own merits, using all the information available and requesting additional information as required. Think about and plan your assessment and develop an individual management plan and strategy for every case. Current strategy and future strategy.

13 Purpose of Claims Assessment is: Assess and pay genuine claims. Deny claims that do not meet Policy Terms. Assess financial, medical and/or occupational, non disclosures or misrepresentation, product interpretation and legal issues. Provide utmost customer service to the client and adviser. Assess if the duration of the claimed condition is longer than the expected duration for that injury or illness. Assist the claimant back to work, using rehabilitation and other tools.

14 How we assess and get information The Application: If the case is underwritten, it is essential to obtain the Application for Insurance (proposal) to see what the client disclosed and the UW decision. Correct Policy Document pertaining to that cover. The Claim Forms fully completed by the client and their doctor. The doctor needs to be a medically registered doctor and not a physiotherapist, chiropractor, naturopath, psychologist etc.

15 Where do we get this information? (cont.) The claimant: talking to the client will give you a lot of information about the claim, provide missing information and build rapport and customer service. The treating doctor and other health professionals will provide additional information in regard to any history, current and future treatment, diagnosis, prognosis etc.

16 Other information that you can obtain to assist in Claims Assessment IMEs - (Independent medical examinations) Claim has exceeded the expected duration or there are conflicting medical opinions or as recommended by the CMO. Make sure you choose the right examiner for the condition. Send the IME report to the GP in respect of recommended treatment to influence the claim Accountants If a client is unable to provide financial information, you can obtain information direct from their accountant. Forensic Accountants Utilise the services of a Forensic Accountant when we need to analyse complex financial structures or need to do a financial audit of a claim.

17 Other information that you can obtain to assist in Claims Assessment Investigators Factual interviews or surveillance

18 Where else? Underwriting The underwriting file should be obtained on the Policy Application or at the time of any reinstatement. Look at any non-disclosed or misrepresented medical, financial, occupational or lifestyle information at time of claim, compared to time of application. Obtain full details of their history prior to the policy application and refer this to Underwriting to ascertain if a policy would have been accepted. CMOs (Consultant Medical Officers) medical consultants or staff employed to give a medical opinion on a claim. opinion on diagnosis, treatment, prognosis, definitions, suggested future management of a claim from a medical perspective, talk to treating doctors and also educate staff on medical issues.

19 Where else? (cont.) Advisers The Advisers (including brokers) act for the client. They write the insurance for the client and have knowledge of the client and claim that may be useful in your assessment. Any non-disclosure or misrepresentation of information provided at underwriting, you should contact the adviser and obtain a full report from the adviser on how the policy was written. This is also a FOS(Financial Ombudsman Service) requirement. You should keep the adviser informed of what is happening on a claim, within privacy regulations, to provide service to the client and build rapport with the adviser.

20 Tools to aid in assessment: Medical reference guides Medical Disability Adviserdurations and medical info Internet. Research conditions, name and business searches, see if running any other business or hobbies, determine duration of injury and illness, treatment options etc.

21 Your telephone: Is one of the most useful ways of getting information from the client and adviser. It is a great way to build rapport and provide service. Issues are resolved quickly.

22 Starting the process Your assessment should start from day one of when you are notified or receive a claim. Early Intervention on a claim and Utilise Rehab. Fully review all of the information you have and assess any gaps in information. Start to build rapport with your client and assess authenticity of claim. Check the policy is in force and you have the correct policy document and definitions. Check for any exclusions.

23 The initial claim form: Holds a lot of useful information and is key in your assessment. If the policy is less than one year old and the claim is for a degenerative or recurrent condition, you will need to look at the medical history and any potential non-disclosure. Decide if you need any further information. Does all information meet policy definitions?

24 Occupation A thorough understanding of a client s occupation and actual duties is an integral part of assessing your claim. Cannot assess the impact of their disability if you do not understand what they do A disability does not mean inability to work. Functional capacity Is their occupation the same at claim and policy application Sedentary or manual

25 Income Understand their income We insure their income and are replacing 75% of their income Look at time of the policy application and at claim time. agreed value and indemnity policies. Important aspect so we are not overpaying the insured

26 Income (cont.) Agreed Value Financial evidence should have been provided at underwriting and we agree to pay 75% of their pre-policy income plus indexation at claim time. Indemnity Policies No financial evidence was provided at underwriting, so the client will need to provide proof of income at claim time and we pay 75% of pre-disability earnings.

27 Medical history Obtain a client s full medical history to assess if there is any nondisclosure or misrepresentation of medical information at the time of policy application. A full medical history also gives you a full picture of their medical status and how past conditions impact on their current condition. Request Medicare Aust records list of all doctors seen, dates Then clinical notes

28 Other details to look at as part of your assessment Check the client s address. Do not accept PO boxes. Residential address in case we need to visit the client or conduct surveillance. Does their phone number match the area they live in? If not, they could be living (or working) at another location. Do they always give a mobile number? Most people, if not all, have mobile phones. However, if someone is disabled, most of the time they should be at home and can use a landline.

29 Other details to look at as part of your assessment (cont.) Is there noise in the background? Indicator of possible work activity or renovating a house. Discreetly query this with the client or organise surveillance. Activity Statement or Activity Diary to obtain a statement from the client as to his/her exact activities. Useful once you obtain surveillance, to compare what they are doing and what they say they are doing.

30 Medical information Check to see if their doctor is suitably qualified. They need to be a registered medical practitioner, not a psychologist, physiotherapist etc. Are they seeing a specialist? Who referred them? This is useful information to gather a full understanding of their condition and capacity.

31 Other resources to assist you in your assessment (cont.) ASIC business searches Vedacheck and National Databank Services:- can determine if a client has registered a business, or is bankrupt. Other insurance claims. IRAA (Insurance Reference Association Australia):- search of all Life Insurance claims. Utilise reinsurer partnerships and work within Treaty arrangements

32 Keys to assessment Case conference the claim Seek input and advice from colleagues and team members with more experience. Use all resources and tools available to affect successful outcomes on your claim. Manage a portfolio of claims (case load)- requires time management Strategies for each claim Impacts financial results of the Company

33 Conclusion There may be different approaches and ideas for any one claim. Work within the policy terms and Insurance Contracts Act.

34 Damian Thornley Head of Product+Pricing MLC Group Insurance Group Insurance An Introduction

35 Agenda What is group insurance? The market for group insurance products Principles of group insurance A typical group insurance product offering Key challenges Slide 2

36 What is group insurance? The basic principle of group insurance is that a group of people all contribute to a pool of funds that is used to cover death and disability that members of the group suffer. Group Insurance is akin to the concept of wholesale buying and it offers a cost effective way for a well defined group of lives to access cover. Slide 3

37 What is group insurance? Group insurance involves the insurance of a group of people linked by a common factor ( Eligibility ); Super Fund or Employer individual decision ( selection ) must be removed from cover decision Key risk factors of the group determine what benefits will be offered and at what price. Importance of occupation rating. Benefits offered in a formula style ( Benefit formula ) Slide 4

38 Slide 5 Group insurance market how it looks

39 Group Insurance market growth Fast growing market ~ 14%pa over last 5-years, due to increase in what Trustee s have deemed to be an appropriate Default cover level. Business is typically remarketed by a Broker every 3-6 years to review Insurer pricing and service. Industry Funds is fastest increase growth segment Distribution is by Brokers that specialise such as Mercer, Marsh, AON, Rice Warner Actuaries, IFS, Willis, JLT etc Slide 6

40 Principles of group insurance Automatic acceptance and the concept of automatic acceptance limits (AAL) Eligibility and becoming an insured life Rate guarantee (3-yrs) Slide 7

41 Group insurance products Two group insurance products are typically offered by most group insurers Group life insurance (lump sum benefits) Death Cover (including terminal illness) or; Death Cover (including terminal illness) and Total and Permanent Disablement (TPD) Cover. Slide 8

42 Group Income Protection Group Salary Continuance Provides a monthly benefit to an insured life (up to 75% of salary/income) for a member who is unable to work due to illness or injury. An additional amount of up to 10% is sometime insured to cover the life insured s pre-disability salary income in the form of a Superannuation Contribution Benefit. Benefit period / Waiting period Slide 9

43 Opportunities in Group Market Market product differentiation / proposition innovation; Eg, MLC Best Doctors Pricing margin pressure BUT >> A great place to work Slide 10

44 LDG Introduction to Underwriting 28 th July, 2011 Warren Page Chief Underwriter, AMP

45 Agenda What is Underwriting Role of Underwriting Why Underwrite Underwriting Requirements Assessment Outcomes Underwriting Philosophy Case study 2

46 What is Underwriting? The process of obtaining and assessing information to determine on what terms, if any, an applicant can be insured 3

47 What is the role of the Underwriter? To insure as many people as possible, with the RIGHT product, at the RIGHT price, and setting that price, with MINIMAL inconvenience to the client. 4

48 Why do we underwrite? Reduce anti-selection Maintain competitive pricing Ability to offer some protection with the use of exclusions Protect the company brand and image 5

49 Risk Continuum LOWEST RISK HIGHEST RISK Standard rates Special terms/defer/decline approx 85% approx 15%

50 Underwriting Considerations Medical conditions Financial Occupation Past times Art vs Science in balancing the multiple factors and variables

51 When we ask for underwriting requirements Application and personal statement + questionnaires Medical and financial - age of applicant / level of cover applied for Mandatory and discretionary - level of cover applied for - disclosures from the applicant Product specific - Term/TPD, Trauma and IP/TSC Client specific disclosure 8

52 What we may ask for Medical questionnaires medical exam Express Check PMA report blood tests resting ECG exercise ECG blood pressure readings Financial questionnaires SOA ITR s and assessment notices employment contracts P&L and balance sheets loan agreement independent valuation of business spirometry urinalysis 9

53 What we won t ask or pay for Invasive tests eg colonoscopy Genetic tests Tests recommended by a medical practitioner that the applicant has not yet had performed Tests or examinations for the purpose of diagnosing a condition ie, the applicant has symptoms suggestive of an underlying condition, we would defer pending investigation 10

54 Possible Assessments: Accept the application as proposed Increase the premium Apply an exclusion Modify the policy benefits Decline the application 11

55 Underwriting Philosophy To offer sensible, sustainable underwriting terms first time. To offer terms based on a thoughtful and reasonable assessment of the evidence presented, having regard to the individual circumstances of the case. We will make underwriting decisions as soon as possible to see the customer covered. We will make our underwriting decisions on the minimum necessary information and documentation. Keep customers fully informed on the progress of each application and provide a logical reason for any decisions we make. Where it is not possible to offer terms that are agreeable to an applicant, we commit to seeking to offer alternatives where practical. 12

56 Case study Occupation Builder Self employed since 4/11 Age is 30 years old Height 180cm, weight 85kg Non-smoker, drinks 2 beers per day Income in $80,000 Income in $80,000 Some back pain in 2005 to or 3 times per year.

57 Case study Application includes:- $2m death and $1.5m TPD IP for $6000pm, 4 week waiting period and benefit period to age 65. What information do we need now?

58 Case study continued Is the occupation insurable? Is the death benefit justified? Client is recently self employed - how do we look at this? Is the income net of all expenses? What is the nature and area of the back pain? What is the treatment for the back pain?

59 Thank you