Updated: Jun 9
What happens when a disability or accident claim analyst misses one important line in the medical record that leaves them believing there was misrepresentation at the time of underwriting, and that one line made it clear that the serious medical condition had resolved before the policy was put in force? He or she wrongly denies the claim.
What happens next? The insured appeals the decision, and with the information clarified, the insurance company (obviously) now pays the claim. But, at the very least this leaves the insured very dissatisfied, and they may even file a complaint with their state insurance department (or worse yet, talk badly about the company!).
This minor, but meaningful, human error reminds me of a great blog by Sam Friedman (Deloitte) about Claims satisfaction:
“...In such cases, even if they (insurers) eventually pay up, any delays or unnecessary hassle may still leave policyholders with a bad taste in their mouths. This could undermine retention and may prompt complaints that go viral over social media. There even might be regulatory implications.”
Thankfully though, the claim was analyzed with the DigitalOwl system which immediately flagged the medical information that the claim analyst missed, and the insured’s claim was approved right away. The best information led to the right final decision that helped keep the insurer's promise.....to pay all legitimate claims quickly and fairly. Happy claimant, happy customer for life.