Tip #5: Read What Is Written Not What You Expect to See Written
This tip can be useful when looking at statements, such as witness or police statements for a death claim or claimant statements about the history of an event. It’s important to look at precisely what is said and not just assume the words used are the ones you anticipate because you’ve already started to form a view about the event. Our brains are very good at filling in gaps by referencing past experience and knowledge, but in claims management sometimes a written statement can provide a great deal of insight. So be careful to actually read the words that are written and not allow your brain to go ahead and populate the words you expect to see.
Tip #4: Communication
Buying or selling a house is all about “location, location, location,” but in claims management, it’s “communication, communication, communication.” When we’re adjudicating claims, there are often multiple parties involved, and we need to bear in mind that different forms and styles of communication might work for some people and not others. For example, if you’re talking to an agent who is familiar with the product and policy, you can assume that person knows more than if you were talking to the insured. People will not have the same knowledge base or experience, so you need to tailor your communication accordingly. Speaking with people verbally, either face to face or on the phone, then following up with written communication is often the best approach, as you can confirm what was discussed, what was agreed to, and what the action points are.
Tip #3: Does It Make Sense?
We often ask ourselves “Does it make sense?” at the point of reaching a claims decision. Consider the sequence of events, the way the claim was presented, the treatment, the impact, and the ongoing effects. Has this formed a pattern you are familiar/satisfied with? Claims management is all about patterns, and the best claims adjudicators know how much information they need to get. You don’t have to have everything, but you need to have enough to understand the circumstances and how they relate to the policy. “Does it make sense?” is a key question to ask as we get to the end of the adjudication process.
Tip #2: Is There Any Other Benefit Definition That Might Be Met?
If the benefit that has been claimed does not meet the definition under the policy, then take a step back and consider whether there might be another benefit definition that could have been met. The insured or beneficiary who has submitted the claim may not be that familiar with the product and is unlikely to understand all the definitions. We are the experts on our products, so it’s important for us to make sure entitlement to another benefit is provided where appropriate.
Tip #1: Is It the Right Thing to Do?
This question is fundamental to claims management. When you come to your claims decision, when you’ve considered all the medical, legal, and circumstantial aspects, and when you've consulted with all of the experts, take a moment to ask yourself: "Is this the right thing to do?” It’s important that you can confidently answer this from a reputational point of view, but it's also worth bearing in mind that if the case goes to the regulator, ombudsman, or legal arena, you may have to explain why you reached the decision. You should always be comfortable and confident with the outcome.
I am known for including quotes in my articles and presentations, and this one effectively encapsulates my feelings about my 44-year career in the insurance industry:
"I may not have gone where I intended to go, but I think I have ended up where I intended to be."
- Douglas Adams