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New Tools, New Opportunities in Claims

Robert Regis Hyle | February 28, 2017

Most emerging technologies bring about not only the ability to integrate and leverage information, but the availability of new approaches to revolutionize the way organizations and people view challenges, such as reconstructing a problem based on new information.

Using claims data is part of the fundamental rate making and underwriting criteria. Some carriers even look at the claims data in detail as part of product innovation efforts.

“Insurers look at things like claims denied for lack of coverage or where there was only partial payment,” says Karlyn Carnahan, research director for Celent. They then decide whether to create coverage. Most of the uses involve making better decisions and whether to intervene more quickly and effectively.”

Sedgwick Claims Management Services, a third-party administrator, has grown from administering workers’ compensation claims to managing a range of Property & Casualty, disability and leave, and other specialty claims and administrative needs.

The company processes tens of millions of claims annually along with hundreds of billions of dollars in medical bills. The need to tap into that huge amount of information comes with a responsibility to the TPA’s clients and the industry as a whole, explains Jarrod Magan, Sedgwick’s vice president, IT decision system support.

“I'm excited about the ability to leverage real-time metrics captured by wearable devices to help nudge people to make better choices,” says Magan of just one aspect of Sedgwick’s data studies. “We are already seeing examples where the data is processed through machine-learning algorithms to provide personalized insights and guidance back to the individual from a health perspective or even through telematics. Over time, it can result in lower healthcare premiums, auto premiums, and an increase in overall productivity.”

Magan is convinced the industry has barely scratched the surface of what's possible. Understanding and applying new and creative ways to use information will be essential to our way of life as we move forward. As these tools come together, smart organizations will begin to think about how to best leverage the data to offer products differently or in a more streamlined way to their customers.

Insurers that can figure out whether a claim is likely to result in higher medical costs, litigation or fraud are ripe for using claims data. If they can get some predictability in those areas they can have a significant impact on the results of the claim, according to Carnahan.

Carriers look at data to determine such matters as whether to use inside or outside adjusters and how to manage staff in other parts of the organization. Customer experience journey mapping, explains Carnahan, tends to be discreet across specific activities. Journey mapping will look at places where the carrier touches the policyholder and tries to optimize the experience.

“That's a good area of opportunity for carriers to use their claims data,” she says. “It’s not so much about what caused the claim, but the metadata on how the insurer engaged with the carrier and how to improve the customer experience.”

So much data remains siloed and not shared. Carriers struggle with how to free that data and create data warehouses that can be useful across the board. Some carriers take claims data specifically to underwriting and if the claims data reveals a driver on the policy that underwriting was not aware of, that can result in a pricing increase. Another example comes if claims behavior for a particular individual is excessive. In that case, underwriting would want to know that at the time of renewal.

There also is a movement to pool claims data inter-company across the industry, which Stephen Applebaum, managing partner, Insurance Solutions Group, reports is being done successfully in Canada right now. There are discussions of doing something similar in the U.S. so auto claims data could be shared on a privacy-protected basis and available for participating carriers to use for claims and underwriting. Applebaum believes we are likely to see this take place in the U.S. over the next three to five years.

Every company has a significant amount of data concerning their exposure, points out Magan, so it is critical to look for additional sources of information to draw a more complete picture of what is taking place.

“Maybe that detail is in your CRM system, or perhaps you need to get it from the client directly,” he says. “There’s no shortage of open sources of information available from the government and other agencies. How can that information be used to turn an otherwise catastrophic claim into a non-event.”

Within Sedgwick’s IT department, the staff performs thousands of interfaces each month—everything from multiple daily feeds to a carrier's downstream system or even back to the client, as well as receiving interfaces in kind. Increasingly, APIs and web services have become, “the thoroughfare of information transit,” according to Magan.

Magan views it as Sedgwick’s responsibility to leverage available data in a way that can limit exposure, mitigate durations of claims, and increase the satisfaction by all stakeholders. “And obviously, where possible, the Holy Grail: prevent a claim from ever occurring,” says Magan.

To illustrate the point, Magan explains a company with an extensive automotive fleet can tap into real-time GPS information and predicted weather conditions. The more tightly integrated they are with that information, the better the opportunity to incorporate the information into the company's workflow.

“When conditions are unfavorable along a driver's route, alternative routes can be sent to the driver in real time,” he says. “All of this can happen upstream from a claim that never occurs. That's incredibly powerful and starts with all the sources of information and how to use them to affect what is occurring.”

 “The trend began with Big Data and data will continue to get even more massive,” says Magan. “It comes down to how best to leverage that information and whether it drives actionable insights to make better decisions.”

Customer Service Needs

Insurers need only look at the way society interacts to know they need to adjust how they communicate with customers. “It's largely mobile, extremely social, and everything is online,” says Magan.

Personalization is critical and this includes the choices an organization provides to the policyholders that interact with them. The days of a one-size-fits-all approach are gone. It’s not just Millennials, either. Baby Boomers and other generations have professed their own particular needs.

Organizations need strategies that consider these preferences in order to support marketing, communication, and ways they interact. For some people, that's never speaking with a person and interacting through a chat session, which is increasingly driven by some level of AI. For some, it's a phone call. For others, it's a text exchange that can take place asynchronously to better fit within a busy schedule.

One of the keys to better customer service include dealing with the customer expectations to be more involved in their claim. They expect to participate and collaborate and expect to be kept informed instantly, explains Carnahan. Customers want the ability to proactively notify a claimant a check has been issued; have a portal to communicate with an adjuster; mobile apps to report a claim and do a video estimation with an adjuster. These capabilities are typically not supported in legacy systems.

“Modern systems with open APIs have these capabilities already or can be integrated with point solutions,” she says. I won't go as far as saying everyone should replace their system, because that's not an accurate response, but if you want to extend these new capabilities to drive customer experience and meet customer expectations, you need more tech capabilities, many of which are found in the modern systems but can also be accessed through point solutions.”

Whether to replace a system, build a new one or wrap tools around the legacy system depends on the capabilities of the carrier and what capabilities they are trying to extend. Extending uses of technology allows carriers to deliver more sophisticated levels of customer service and customers expect that. Without it, insurers run a risk of being left behind competitively, adds Carnahan.

A big development in service improvements are the online and mobile claims reporting capabilities insurers push out to policyholders, according to Applebaum. These options give claimants the ability to report claims online directly to a carrier's website or at least open the claim.

Not many carriers have the ability to give policyholders the ability to complete the claim online, but most can start the claim process and receive a call from the adjuster. As far as mobile claims reporting, almost all the top 10 P&C carriers offer mobile apps that include claims reporting.

“USAA is the best example of the richest functionality on an app because they have a big financial services offering as well as an insurance offering,” says Applebaum. “All carriers do it to one degree or another, though.
That capability includes having the policyholder take photographs of the damage and send them for claims processing. In some cases carriers are using third-party outsource vendors who create estimates based on the photos. Those images, in many cases, result in claims payments being made within 24 hours of the First Notice of Loss and sending policyholders on their way to take care of the claim on their own or to be referred to a collision repair shop.

Texting on the status of claims is growing rapidly, adds Applebaum. Carriers are developing proprietary solutions so when a claimant takes their car to a repair shop they receive a text every few hours on the progress of the claim. There normally is a link to the adjuster if the claimant has questions about the claim.

Claims Prevention

Most carriers do not do much work in claims prevention or risk management, points out Carnahan. They may put some static content on their website and hope the customer goes there and takes advantage of the information. Some go further in that their static content to focus on a particular industry on the commercial lines side. Some carriers have put tools on the site so customers can download training programs.

“We are seeing interesting things on the commercial lines side with collaborative risk management capabilities,” says Carnahan. “Collaboration is a big expectation of generations today—people want to be part of things.”

She cites examples such as having the loss control engineer conduct an inspection and then put together a plan on the customer portal. The customer can see the plan, ask questions, and interact with the inspector. This allows companies to collaborate, communicate, and discuss what is happening with risk management within the organization.

Some carriers on the workers’ comp side are looking at ways to improve appropriate behavior to recover more quickly from work-related injuries.

One other area involves avoiding losses on the product side by embedding behavior within the product itself. If you behave in a manner that likely will generate fewer losses, you are rewarded through the pricing of the product, according to Carnahan. The obvious example of such product changes involves telematics.

“If you are a safe driver, you receive fewer points,” she says. “If you behave well and monitor things, you can receive a benefit. It's not specifically avoiding losses, but it is using a product to drive behavior that theoretically will mean fewer losses.”

A claim is an emotional event, points out Carnahan. Carriers have begun using personalized video to acknowledge the claim and provide the personal emotional connection. The question for carriers is where can they eliminate tasks yet improve the emotional connection and customer service and improve the decision-making process.

Many customers, though, would prefer being notified by a text; they don't want to talk to anybody. Many carriers say the personal touch is what differentiates them, points out Carnahan, but she cautions carriers to understand who their customers are and how they want to be communicated with and then have the ability to communicate in the way the customer prefers.

“The more complex the claim, the more they want to talk to someone, but many customers find it an annoyance,” says Carnahan.

Vendor Services

On the property side, Applebaum has also seen service improvements. With claims on personal property that have been lost through theft or fire, many carriers are able to resolve contents claims in real time at the point of reporting the claim and settling them within hours.

There are times that can't be done, such as when the house is burnt to the ground, but if someone steals your laptop, those claims are being settled almost immediately through a combination of photo imaging and powerful data bases that can take a description of an item and find a match for it at a retailer or wholesaler and have it either shipped out or a payment is made to the policyholder for the appropriate cash value for the claim.

“Contents used to take weeks to resolve; now they are more often taking days,” says Applebaum.

The accuracy of contents claims also is improving dramatically now that third-party providers are integrated with retail data sources. Amazon's database, for instance, is being used by contents providers when evaluating a claim. They know that in a certain city the value of a 55-inch TV set is precisely X amount of money and that is the lowest available price for the item that is lost.

“With that type of accuracy comes savings for claims,” says Applebaum. “Carriers are integrated with Home Depot and Lowes and many of the big-box retailers as well as the virtual retailers.”

The elimination of fraud from claims—auto or property—is a benefit to insurance companies as well as policyholders. Fraud represents as much as 25 percent of auto insurance premiums, so eliminating fraud brings value to everybody. The technology carriers are using effectively to fight fraud includes advanced analytics and data visualization.

Using the analytics tools and visualization tools, carriers are able to provide entry level adjusters with a powerful fraud identification and deterrence capabilities before the money is out the door and there is still time to do an investigation and, if appropriate, deny a claim, explains Applebaum.

“Detection used to happen after the fact and carriers can't afford to try and recover a few thousand dollars from an individual,” he says. “If you can prevent that before the claim, that's a win for the carrier.”

The use of injury causation software is a new development that allows carriers to determine whether a claim injury from an automobile wreck is likely a result of the accident dynamics—speed, direction, impact, location of the individual within the vehicle. Applebaum points out this is not widespread, but it can result in lower casualty payouts, which is the biggest amount of any auto claim.

The Final Word

Innovative startups are pushing established companies to revisit the way they do things and the products they offer. Every growth minded organization should be considering crowd-sourcing innovation from within or partnering with innovative startups to offer new solutions, explains Magan.

“Companies must actively review and advance these solutions to not only incorporate the technology that's just around the corner, but really look at the technology that is just beginning to show up on the hype cycle,” he says. “The organization must ask questions like how blockchain can impact the business and the way they interact with customers. The same with chatbots and virtual and augmented reality. Technology has the ability to transform this industry and the way people interact with the world.”

 


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