Tip #10: The Value of a Cup of Tea

When you're puzzling over a claim, take a break and make a cup of tea. You'll often find it gives your brain a chance to reset and clearly see what was concerning you. Never underestimate the value of a cup of tea.

Tip #9: There's No Such Thing as a Silly Question

Claims sometimes can be overwhelming, with lots of complex medical, financial, and legal information. It is not always obvious how to proceed or where to go for further clarification. If you’re unsure or want additional information, just turn to the person who can provide that support. If you don’t know, you don’t know, and when in doubt, just remember that there’s no such thing as a silly question.

Tip #8: Critical Thinking and Intuition

Critical thinking involves making decisions based on objective analysis while guarding against personal bias. Intuition means acting on professional instinct. It may seem contradictory to say that critical thinking and intuition are equally important, given that intuition is much harder to define objectively. But in claims management, the best assessors are those who use both critical thinking to make sure they’ve covered the key information and intuition to stay in touch with their gut feelings. This combination is key.

Tip #7: Claimants Have a Right to Feel Heard

We must ensure claimants are heard and their concerns have been validated. Claims management can be very involved, with different pieces of information, definitions, and various complex aspects to consider. But it’s always important to acknowledge that the claimant has suffered something potentially traumatic and life-changing. The event may not always give rise to a payable claim, but it could still have changed the insured's self-perception and may be impacting family members and the wider community. It is important the claimant feels the insurer, and all other parties involved in the claim’s management understand he or she experienced a significant life event, even if it does not rise to the standard of an “event” under the specified policy definition.

Tip #6: Need to Know vs. Nice to Know

We must sometimes take a step back in the claims management process and ask: What do we need to know vs. what would be nice to know? Claims assessors tend to be nosy and want to understand the full details of the situation and the outcome to date and to evaluate this against patterns we’re used to. But sometimes we should ask ourselves if the information is critical to enabling a claim decision, or whether it is just something we’d like to know as an additional piece of information, which may not necessarily be critical. It is also sometimes worth looking back at the file for existing information that could be used. This information may not belong in the nice-to-know space but rather could provide enough support to make a decision.

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 with/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.