Claims: The Human Face of Insurance

We're delighted to showcase this very informative article on insurance claims, written by Dexter Morse, as first printed in Captive International...

Claims is a people business, and there are many lessons the industry can learn from this part of the business, says Dexter Morse, formerly of the International Air Transport Association.

The cost of claims is a major concern for re/insurers in all markets. Claims departments are faced with increasing demands and expectations from all stakeholders within their organisations, as re/insurers are being accused of failing to manage claims effectively and efficiently.

Claims manager are constantly questioned about the accuracy of loss reserves. How does this headline loss impact our balance sheet? Are we paying too much? Are we properly supervising our claims management agents, loss adjusters and outside counsel? Are we compliant with local laws and regulations? As a result great emphasis is being placed on claims and claims practices.

What makes a good claims operation?

It involves the following:

• Communication with the insured should be clear and open. The insured should be fully informed of the stages of the claims process and any investigations being made (such as instruction of loss adjusters or lawyers)
• Liability. The claim should be investigated swiftly and thoroughly and a decision taken on liability early on
• Active and attentive. The claims team should respond swiftly to all correspondence received and verbal communication should be followed up with written confirmation to avoid misunderstandings
• Investigation. If there are policy issues or liability matters, the claims manager should deal with these promptly and professionally and have a definite action plan in mind
• Money. Payments should be made promptly (after all this is why insurance policies are incepted—to pay claims). In the event that the claim is not covered by the policy then the claims manager should advise the insured as soon as reasonably possible in writing
• Subrogation. If there is the possibility to recover from a third party such actions should be pursued swiftly and zealously to ensure success and to avoid any time bar issues

Claims departments are a mine of valuable information that is frequently overlooked by the wider organisation. The claims department is perfectly placed to see if the insurance policy responds in the way the underwriter actually intended (assuming the underwriter knew what s/he intended in the first place) or if the wording was too wide or obscure.

Managing claims effectively

Claims is a people business. Most insureds have more contact with the claims department than any other department. The claims team can inform underwriting if the insured is satisfied with the product or how it can be tailored to the client’s needs, thus permitting the organisation to retain or even increase its business. It can also provide risk management advice to help reduce similar claims in the future for the insured. For the claims department this can increase its visibility.

The claims manager should encourage the wider organisation to listen to the “lessons that can be learned” from claims. For example, large losses can be presented to representatives from underwriting, actuarial, accounting, finance and top-tier management in a “learning session” so that weaknesses can be exposed and improvements made for the next time around.

Claims success stories should be celebrated. This could be a claim that was declined because it was not covered, a fraudulent claim that was uncovered, or a large loss that was reduced because of proactive claims management or a successful subrogation action. These lessons should be published in internal communications to heighten awareness.

It is surprising how many subrogation and other recovery opportunities are overlooked. A systematic approach to pursue negligent third parties or their insurers needs to be adopted and files closely diarised to ensure recoveries are aggressively pursued. Outside counsel are often instructed to assist with recoveries—while they can achieve excellent results, the benefits need to be carefully weighed against the likely recoveries achieved and they need to be monitored closely to assess their effectiveness.

The claims manager and internal audit should conduct regular reviews of the claims files handled in the department to ensure consistency of approach, accuracy of reserving, proactivity of claims management, compliance with claims-handling guidelines, to ensure recoveries opportunities have not been missed and to identify any future training needs for the claims-handler. Such reviews should be well documented for compliance purposes.

Actuaries are heavily involved in the pricing and reserving practices of insurers but the claims department can add words and meaning to these figures. For example, a sudden negative loss development for a client might raise alarm bells with underwriting—this may be explainable as a significant isolated litigated claim in a specific quarter but the account will return to profitability in subsequent quarters.

Underwriters cannot know their accounts if they do not know their insureds’ claims. Underwriters must work closely with their claims colleagues to understand the problem areas and where significant exposures may lie. If underwriters are the mouth of an insurer then claims are its eyes and ears.

Renewal meetings and new business

Where possible claims and underwriting should work hand in hand to project a united front to the client. To facilitate this underwriters should do their claims homework prior to renewal meetings to appear professional and knowledgeable and make the client feel valued. Underwriters should include their claims counterparts in such meetings.

Claims departments also have a valuable role to play in relation to the business the insurer has on its books by way of pre-underwriting reviews. A brief analysis of the claims of an insured prior to writing the business and interviews of key personnel (risk managers/claims handlers, etc) can be enlightening in determining whether to write the risk in the first place and, if so, that it is correctly priced.

The claims function is legally oriented and therefore claims handlers are perfectly placed to know what trends and developments are likely to happen in the legal world which might impact the business in the future. Such information should be regularly shared with underwriting and actuarial.

Outsourcing

Re/insurers constantly debate whether to centralise or outsource their claims activities. Centralisation ensures claims are serviced by nominated staff who know their customers, are attuned to their wishes and thus behave in a manner which consolidates and compliments the insurer’s brand and makes the client feel of stable and secure.

The benefits of outsourcing are flexibility and value. It enables you to tap into an established knowledge and skills pool. A company that outsources its claims does not have to deal with the employment problems associated with fluctuations in claims workloads. When workloads fluctuate, the company does not have to train claims-handlers quickly or make them redundant—it simply passes this on to the outsource provider, who as a result of its scale are better able to deal with them.

An additional cost of outsourcing is the regular audits required by the claims department to monitor the standard of the service provided by the outsource provider. By outsourcing the insurer is passing control to a third party and entrusting them with the company’s money and reputation.

Claims automation

Certain types of claim, especially non-injury motor and household are becoming increasingly automated.

Research indicates a fundamental positive shift in attitudes toward claims automation as insurers are increasingly open to automation. Currently the focus is on how artificial intelligence and machine learning can assist with decisions around damage assessments, segmentation and payouts. They are also starting to experiment with more innovative technologies as they develop trust and competency in virtual processes.

Prior to the COVID-19 shutdown, less than 15 percent of claims were handled virtually. Based on research by LexisNexis Risk Solutions, titled Future of Claims Report 2021, virtual claims handling increased to nearly 100 percent after the first shutdown was implemented. Almost a year later, virtual claims handling has settled to a level of just over 60 percent.

The public is embracing this movement online: 62 percent of people surveyed by LexisNexis viewed the convenience of being able to submit a claim any time/anywhere as a perceived benefit of automated claims handling. Other perceived advantages included the faster settlement of claims (55 percent), increased transparency (45 percent), and increased accuracy (34 percent).

Customer age has a role to play. Millennials and GenX-ers tend to be more comfortable with technology and are especially receptive to automated claims processing and the many benefits it affords. Two-thirds of Millennials and just over half of GenX-ers say that COVID-19 has had at least some influence on their being more open to filing a claim online.

LexisNexis research indicates that 79 percent of Millennials and 64 percent GenX-ers are now comfortable with automated claims processes, which is a significant increase on 2019 figures. Convenience, faster claim cycles, greater peace of mind, and increased accuracy and transparency are all cited as benefits of an online claims process. For these two groups in particular, appreciation of these benefits has increased by as much as 11 percent over the past two years.

For baby-boomers the focus tends to be on ease-of-use of an insurer’s website or apps, rather than on having the option to use online tools to file a claim, and many remain uncomfortable with technology in the claims process.

Although most consumers embrace virtual claims processing, they are dissatisfied with some of the tools. Generally, the more questions they have to answer through a self-service process, the less happy they are with it. While they like the idea of self-service, the reality is leading to some disappointments, especially for more complex claims.

Worries also exist in relation to security with more than 60 percent of the consumers surveyed raising concerns around the security of their personal identifying information (PII) when submitting claims virtually. This is consistent across all age groups. The LexisNexis research indicates eight out of 10 claims executives see identity verification as a primary concern with virtual processing. They understand the importance of cybersecurity but are struggling with how to ensure it in their claims processes.

Training and ongoing education

Training and ongoing education are vital to success. It is essential that claims staff are informed of the latest laws and regulations and changes in public attitudes (since the public compose the juries which make awards, especially in the US) to ensure reserves are accurate, contracts are interpreted appropriately and sound decisions are made regarding whether to settle or fight a litigated or arbitrated claim.

Control of training is important to ensure claims staff have a consistently high skills level, access to detailed, comprehensive, up-to-date reference material and are able to contribute to and draw from an extensive pool of expertise.

A large central claims department provides economies of scale and the opportunities to cross-train and produce multi-skilled staff who are able to meet changes in the portfolio and market place. It facilitates the development of an extensive knowledge pool, avoiding the unnecessary duplication of expertise.

Staff are the most valuable resource in any claims department. Large, centralised claims departments can provide interesting and varied career paths, leading to increased job satisfaction and better staff retention rates. Obviously this is better for the organisation and the customer since the best claims service is offered by happy and experienced staff.

Clear, measurable performance goals should be established which reflect the organisation’s goals and aims and are fully supported by the claims team. Senior management should be open and involve the claims team in the setting of the goals and objectives to ensure a complete “buy in”.

The claims team must handle claims in good faith.

The human touch

Many consumers prefer a mixture of self-service and claims handler interaction and want the opportunity to opt out of self-service and access a representative whenever they wish to.

While online self-service and virtual processes are valued for their convenience nothing can replace the human touch of speaking to a real person which increases the consumer’s comfort levels and proves that claims is, and always will be, a people business.

#claims #insuranceclaims #legalcounsel #bermudaclaims #bermuda

Used with permission. Dexter Morse has worked as a legal, claims and risk consultant at various leading global re/insurers, and was formerly director of global insurance and risk management at the International Air Transport Association.