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Flag Hidden High-Risk Claims Before they damage customer relationships America’s Claims Event 2014
| Date post: | 16-May-2015 |
| Category: |
Economy & Finance |
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Flag Hidden High-Risk Claims
Before they damage customer relationships
America’s Claims Event 2014
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High-risk claims that are neglected by insurers
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High-risk claims will wreak havoc if not detected quickly, resulting in inaccurate reserves, increased severity, longer cycle time and customer service issues
4Source: JD Power & Associates
Only 50% of policyholders would definitely renew if less than “delighted”
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Insurance companies overlook valuable indicators for high-risk claims that are hidden in claims files
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To proactively find high risk claims, you must analyze
free-form text and scanned documents across thousands of
claims files –
the 50%+ of information your company cannot reach today.
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More than 50% of supervisors spend 2-4 hours and 27% spend 4-6 hours reviewing staff claim files
Sources: Towers Watson “Insights: Property & Casualty Claim Officer Survey#8, Aite Group analysis
Reviewing direct reports’ files
Attending claim‐related meetings
Attending training
Reviewing reports
Email / company communications
Handling their own data
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Claims Adjuster Note – FNOL Spoke to clmts sister, clmt taken to hsp for tx.Ankl is sprained, clmt has aircast. Tx and released. Given crutches, clmt OOW. Neck/back pain and some numbness in hands. Following up with PCP in a couple of weeks. Clmt may retain an attorney. Car totaled, appraiser has seen. Clmnt not in rental due to ankle injury.
Case Study #1 – High Exposure
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Claims Adjuster Note – FNOL Spoke to clmts sister, clmt taken to hsp for tx.Ankl is sprained, clmt has aircast. Tx and released. Given crutches, clmt OOW. Neck/back pain and some numbness in hands. Following up with PCP in a couple of weeks. Clmt may retain an attorney. Car totaled, appraiser has seen. Clmnt not in rental due to ankle injury.
Case Study #1 – High Exposure
Analysis must detect abbreviations,
misspellings and claims vernacular
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Claims Adjuster Note – 14 Days after FNOL Clmnt called with update. Ankle pain getting worse. Went to e/r and now that swelling is down, Xrays show fx’d ankle. Fx is displaced and they are recc sx with ORIF. Clmt will be OOW as construction worker for some time. MRI ordered for spine due to tingling sensation radiating down arms. Possible HNP?
Case Study #1 – High Exposure
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Claims Adjuster Note – 30 Days after FNOL Clmt called back. Sx has been completed on ankle. Possible PPD rating will be assigned. MRIresults are back and are negative for HNP, though DDD is present.
Case Study #1 – High Exposure
Continuously analyze data, aggregate
results from multiple notes, determine
context
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Claims Adjuster Note – 30 Days after FNOL Clmt called back. Sx has been completed on ankle. Possible PPD rating will be assigned. MRIresults are back and are negative for HNP, though DDD is present.
Case Study #1 – High Exposure
Actions:
• Properly segment claim
• Complete supervisory review
• Develop on-point action plan
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Case Study #2 – Prescription Abuse
Claims Adjuster NoteInjured worker suffered a soft tissue back injury and is unable to RTW. Has been placed on Oxy. Medical records indicate hx of depression and ETOH abuse. Employer indicates on intake sheet that worker was on perf mgt. Plan is to collect medical bills and records, pay meds and wages. Goal is to have clmnt RTW in same capacity.
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Case Study #2 – Prescription Abuse
Claims Adjuster NoteInjured worker suffered a soft tissue back injury and is unable to RTW. Has been placed on Oxy. Medical records indicate hx of depression and ETOH abuse. Employer indicates on intake sheet that worker was on perf mgt. Plan is to collect medical bills and records, pay meds and wages. Goal is to have clmnt RTW in same capacity.
Analysis must determine context of
flagged indicators
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Case Study #2 – Prescription Abuse
Scanned Document – Prescription Records
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Case Study #2 – Prescription Abuse
Scanned Document – Prescription Records
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Case Study #2 – Prescription Abuse
Scanned Document – Prescription Records
Actions:
• Review loss reserve for potential adjustment
• Refer to nurse case manager for pain medication management
• Contact treating physician for collaboration on treatment regimen
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Dashboard Demonstration
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Case Study #3 – Fraud
Claims Adjuster NoteClear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty.
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Case Study #3 – Fraud
Claims Adjuster NoteClear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty.
Suspicious relationship detected
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Case Study #3 – Fraud
Claims Adjuster NoteClear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty.
Analysis must include data from multiple sources, including
scanned documents
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Case Study #3 – Fraud
Claims Adjuster NoteClear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty.
Actions:
• Implement early referral to SIU
• Schedule IMEs for all claimants
• Begin surveillance of claimants
• Schedule statements under oath
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Case Study #4 – Underwriting
Claims Adjuster NoteHomeowner has ice dams, stating that ceiling was leaking for several hours. Visited home to inspect and write scope of damage. PH has an aggressive dog on premise that had to be restrained and put into another room when I entered the residence. Looked to be a pb.
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Case Study #4 – Underwriting
Claims Adjuster NoteHomeowner has ice dams, stating that ceiling was leaking for several hours. Visited home to inspect and write scope of damage. PH has an aggressive dog on premise that had to be restrained and put into another room when I entered the residence. Looked to be a pb.
Timely claims information is critical
to making better underwriting
decisions
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Case Study #4 – Underwriting
Scanned Document – Appraisal Form
APPRAISER COMMENTS
Upon arrival at the residence, an angry dog had to be put on a leash by the homeowner and secured outside.
Following this incident with the dog, the homeowner was cooperative, provided a view of the damages and answered all questions in a thorough manner.
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Case Study #4 – Underwriting
Scanned Document – Appraisal Form
APPRAISER COMMENTS
Upon arrival at the residence, an angry dog had to be put on a leash by the homeowner and secured outside.
Following this incident with the dog, the homeowner was cooperative, provided a view of the damages and answered all questions in a thorough manner.
Actions:
• Identify potential high-risk information in claims files
• Automate delivery to underwriting team
• Make data-driven decisions about who to underwrite, who not to renew and who to charge a higher premium or deductible
27Source: Aite Group
Approximately 15% of loss costs and LAE could be saved with the
proper use of technology and process improvements.
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Be Proactive with High-Risk Claims
Minimize risk and costs
Improve customer retention
Decrease cycle time
Maximize resource allocation
Develop timely action
plans
