The interaction of PMI providers and their customers at point of claim can be tricky. Lisa Hall outlines the pitfalls to be avoided
Every insurance claimant deserves exceptional service - after all, it is the claims service that they buy when they hand over their premiums. But perhaps those individuals claiming on a healthcare policy should be given even greater attention and care, notwithstanding the fact that they may belong to a group scheme where their employer pays the premium.
Health claims are very often deeply personal and delicate in nature. They can also be extremely complex, long drawn-out and fraught with technicalities and jargon. So those handling the claim need to be sensitive and alert to the anxieties and priorities of the claimant. After all, this is one of the few times that insurance really does have the potential to be a matter of life and death.
Ensuring top-flight assistance
But there is more to being a top-flight healthcare insurance claims-handler than having a sympathetic telephone manner. The skill-set required is much broader and more sophisticated. Easing an individual through the claims process in a friendly and supportive way is providing only the basic level of assistance.
To provide first-class service, claims-handlers must be able to respond to medical queries in a constructive and positive fashion. They must be alert to the fact that claimants are absorbing information on medical matters from a variety of sources - doctors, consultants, the media, the internet, friends and family. When there is a need for verification or further details on such matters, the claims handler will often be their first port of call.
Given that the call may have been triggered by something the person has just read or heard, the claims-handler may be unaware of the details and may be unable to respond in a constructive manner during the course of the conversation. Where this is the case, they must be able to offer reassurance that they will respond more fully as swiftly as possible, and they must then be able to access a competent and confident answer within their organisation without delay.
This calls for streamlined internal communications and for customer relationship protocols that ensure the original call is not forgotten about and is dealt with effectively and as soon as is practicable.
This subject is a continuing issue for health insurers. Rarely a day goes by without a story in the news that has a link to medical treatment. There are breakthroughs in the way conditions are treated, new drugs are launched or details are released about those being developed. There are also regular changes to NHS provision or announcements from the National Institute for Health and Clinical Excellence.
Little wonder then, that those who are ill or injured are likely to want some clarity - because the potential for confusion and perhaps even distress is considerable.
Too often, insurers promise long and deliver short. Advertisements and brochures make a great deal out of the quality of service on offer, but gaps can exist between the promise and the reality. It is a responsibility for us all to eliminate these whenever they are identified.
The first step, as is so often the case, is to get the insurer's corporate culture aligned correctly. This means recognising the importance of the claims-handler as a key point of contact, and then providing the training and support they need to provide relevant, timely and, above all, clear and accurate information.
Queries will always come out of the blue and catch claims-handlers unawares, but the more training and experience they have, and the deeper the knowledge they possess, the better able they will be to manage questions and concerns during the initial call.
For this to be achieved quickly and efficiently, it is necessary to create processes that allow information to be assessed swiftly and then disseminated speedily among claims-handlers. They should also have a base level of medical expertise to enable them to interpret the information they are given and use it wisely.
Achieving a balance
Insurers will want to achieve a balance between keeping claims-handlers appraised of potential areas of confusion or concern for policyholders and claimants while remaining focused on service delivery. The real danger of information overload must be recognised and resolved. The claims-handler must be selective in what they tell clients - there is little to be gained from straying too far into medical jargon or overtly technical areas. The objective is not to display knowledge but to provide precisely the information that will put someone's mind at ease.
When it comes to creating the right approach to service, insurers must work to develop open and effective lines of communication. Information gathered by bona fide medical experts should be cascaded promptly down to the claims-handling ‘front line', and queries should be able to flow in the opposite direction for rapid, decisive responses.
This places the emphasis on the quality of information being transmitted. Insurers need the best medical expertise available so that they have, in a very real sense, their finger on the pulse of what is happening in terms of scientific research and development, medical practice and political sentiment. And it is at this point that judgment calls should begin to be made about what might be useful and relevant to the claimant and what might actually cloud the scene rather than deliver clarity.
Some insurers retain the services of medical experts to keep fully up to speed with the latest developments. This valuable source of information will be supplemented by regular liaison with consultants and specialists in particular cases. And the lessons learned from these should be applied to the whole so that, whenever a nugget of new information is generated, the whole company benefits.
It is the responsibility of the insurance technicians (as opposed to the medical specialists) to ensure consistency across claims-handling teams in terms of the messages given to clients. It is vital that different individuals do not contradict each other or the agreed position on any matter.
That said, things can and do go wrong. But the true measure of an insurer is often how well it responds to problems and learns from its mistakes or shortcomings. It is accordingly essential that there is intensive root cause analysis on any complaints they receive, tracing errors to their point of origin and identifying solutions that apply not only to the case in hand but to any similar instances in the future.
Improving patient journeys
The constant objective must be to improve the ‘patient journey' - any opportunity to do so must be seized swiftly. Companies will consider how best to monitor the quality of service they provide, and work out how best to analyse and determine claimant satisfaction. It may be that clients want deep technical analysis and constant updates on particular issues. Or they may want nothing more than to know that they are being looked after by capable people who have their best interests at heart.
Insurers must also be willing to view claims-handlers as a precious asset in terms of determining claimant needs. If claims-handlers constantly find themselves having awkward, unresolved conversations, then something must be wrong. The insurer must establish procedures whereby frontline staff can detail their experiences and, most importantly, put forward their own suggestions about how matters might be improved.
Good communication is also important when it comes to brokers and corporate policyholders. Clearly, it will never be appropriate to discuss the personal medical details of any particular case, but the insurer should always be on the look-out for trends that might assist risk management or the way policies themselves are written, sold and administered.
Broker-only insurers will certainly also want to have regular contact with those who supply them with business. Brokers provide important insights into what customers are looking for, and this can feed directly into product and process design.
The ultimate conclusion we can draw is that being a health insurance claims-handler is a challenging job - it calls for sensitivity and expertise, and it requires the person doing it to carry on learning on a daily basis. It is therefore critical that the right people with the right experience are recruited and nurtured to ensure the delivery of the highest levels of service to claimants at what might be one of the most stressful times of their lives.
Putting the right people in the right environment and giving them the right tools and support is key to success. It sounds obvious, but the insurers that do it best will be the ones that distinguish themselves from the pack.
Lisa Hall is customer services manager at Groupama Healthcare
