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5 Best Practices for Effective Claims Reviews

With the cost of insurance for businesses rising across many types of coverage, staying on top of trends in the claims portfolio is more important than ever. Spotting problem areas and opportunities sooner makes it easier to develop and implement steps to reduce risk pre-loss and better control costs post-loss. For this reason, many insurers and TPAs promise to conduct claims reviews with their business customers on a regular basis, but the rigor can vary greatly. Practices that have been common historically often lack the nuance and precision that can unlock the maximum benefit for each customer’s unique situation.

Here are five best practices for a wide variety of customers across a range of industries:

1. Assemble the right team

Typically, only the person overseeing claims at the business attends the claims review with key claims staff from the carrier. However, this small team limits the potential for brainstorming solutions and getting full buy-in to implement them. In addition to claims experts, it may also be helpful for the carrier’s loss control team to attend, as well as agent/broker staff.

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From the business customer side, it is helpful to include all key personnel who can facilitate immediate decisions that will impact the ultimate resolution of the claim in an efficient and timely manner or provide other insightful information. This often includes the risk manager, and may also encompass employees from legal, human resources, safety, operations and even the CFO, in some cases.

2. Develop a clear understanding of the customer to set the claims review objective

Broadly speaking, the goal is always to minimize loss costs to help manage the price and coverage of the overall insurance program. However, each business and claims portfolio is unique. One company may be most concerned with how claims reserves are affecting budgets. Another company may have an unusually high experience modification rate that they want to bring down by reducing the frequency of worker injuries. Yet another company may be changing part of their operation and want to monitor claims activity associated with it more closely than business-as-usual activities. The policyholder’s unique objectives should drive decisions about how often to conduct the claims reviews, what types of claims to include and where to dive into the greatest detail.

3. Fully understand and account for the impact of claims on the insurance program

In the initial design of the insurance program, certain coverages may have been limited due to a problematic claims record. For instance, frequent third-party claims for premises liability may have led to restrictions on Med Pay coverage or a higher deductible to give the customer a bigger stake in safety measures.

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Or perhaps the customer hoped for a loss-sensitive program but could only secure a guaranteed cost program due to lack of an internal pre- and post-loss management platform. The claims review should be designed to account for how frequency and severity may affect underwriting decisions so that the policyholder can move toward its coverage objective

4. Choose claims for review according to objectives, not simply dollar value

The default choice for what claims to review is often based on dollar value—e.g., all open claims with incurred losses of $25,000 or more. This approach may miss underlying trends that could lead to severe loss, however. For instance, perhaps a restaurant chain experiences a high frequency of slip-and-fall claims from workers in its kitchens. While these may all have been minor, but it may only be a matter of time until a severe injury occurs.

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With the objective to reduce frequency and the risk of serious injury, the claims review should examine all slip-and-fall claims using data and analytics to uncover causal factors such as food and liquid dropped on floors or seasonal workers with little safety training.

5. Track reserving on a micro level relative to all factors that can affect open claims

Typically, reserving is only tracked from a macro perspective, but this can overlook a variety of factors that could help better manage reserves and ultimate outcomes. For example, are the latest technologies being consistently used to manage costs? Advances in artificial intelligence and data and analytics now allow us to identify treatment providers associated with the best outcomes for injured workers, but how well are companies taking advantage of the recommendations? Early resolution techniques for auto and general liability claims may lower the ultimate cost of claims but cause a short-term bump in claims payments that needs to be accounted for in the customer’s budgeting process.

Potential Benefits

Claims reviews based on these best practices can yield significant benefits, especially when used as part of a holistic approach to managing risk and reducing losses. For example, an early claims review for a new manufacturing customer identified sprain and strain injuries as a problem area. The loss control team then surveyed the manufacturer’s operations and uncovered increased risk due to various manual lifting tasks, such as loading 8-foot-tall plastic silos with heavy equipment in a confined space. Based on that finding, the insurer’s team conducted onsite job hazard analysis supervisory training that included a safe lifting program, online courses and ergonomic risk assessments on a variety of tasks. As a result, within about two years, the program cut the manufacturer’s workers compensation loss ratio roughly in half.

Hurricane Risk Management: Key Considerations Before and After Storms Strike

On Sunday, August 29, Hurricane Ida made landfall in Louisiana as a Category 4 storm with winds of 150 miles per hour, making it one of the most powerful storms to ever hit the United States. Striking on the same date that Hurricane Katrina devastated the region 16 years ago, Ida caused significant wind damage, storm surge and flooding in Louisiana and Mississippi and has left 1 million homes and businesses without power, including the entire city of New Orleans. Ida has now weakened to a tropical storm and will continue to cut through the south before making its way across much of the East Coast, bringing significant risks of wind, rain and inland flooding throughout this week.

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The storm marks another overactive hurricane season officially underway in the United States, prompting business leaders and property owners to ensure they are adequately prepared from an insurance and risk management perspective.

Some key recommendations to consider before and after any hurricane include:

Preventative Measures

First, establish a plan that includes clearly defined roles and responsibilities for preventative measures to protect your building, employees or tenants in the event of a hurricane. This plan should include everything from the identified incident response team and the established internal and external communication protocols to the selected offsite workspace and disaster recovery plan.

It is also critical to have a predetermined contact list for key service vendors, suppliers and contractors—and to build relationships with those individuals in advance. When a storm of any magnitude hits, multiple businesses will likely be affected, so establishing a vendor rapport beforehand allows you to pre-negotiate rates and availability guarantees, helping to save time and money after a disaster.

From a property perspective, ensure that your buildings and structures are adequately protected to mitigate potential damage. Precautionary steps like boarding up buildings, covering windows and landscaping, and fastening anything that could blow away or fall may seem like small considerations, but can significantly reduce damage and losses.

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Additionally, back up important paperwork and IT services to avoid losing valuable assets. Severe weather often causes power outages and other service disruptions that may last longer than anticipated, and key files like property records and facility plans should be safely stored and easily accessible in the event of a hurricane.

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Not only is this important for overall business operations, but it is also easier to adjust claims when you can show that you recently backed up files.

Read the Fine Print

When it comes to your insurance policies, it is critical to verify that your coverage includes appropriate, up-to-date limits and deductibles.

This includes determining if you have adequate insurance based on your location and its respective risk for floods or windstorms. In addition, you should review your policy’s sublimits, which set coverage limits for certain scenarios, so you know what to expect if damage occurs. For example, windstorm, flood and named storms all have different limits based on the typical severity of the type of storm.

Do not wait until the hurricane is coming to evaluate or modify coverage, as this is like trying to insure a burning building, and insurance carriers will be bombarded with requests. Perform these evaluations and changes proactively so you can remain calm knowing the appropriate coverage is in place for any potential threat.

If a hurricane does hit close to home, business owners can typically tap into business interruption insurance and extra expense limits for any losses that occur due to suspended operations resulting from the storm. This also applies to property owners who may need to move tenants to a different location while the property is being fixed—a process that could take several months depending on the severity of the hurricane and the associated damage—and are therefore not incurring rent.

Now What?

If a hurricane impacts your business, implement your disaster recovery plan. Then, as soon as it is deemed safe to re-enter the property, document all damage in detail with written descriptions, as well as photos and/or videos. At this time, take a full inventory of damaged materials, as this will be important throughout the claims process, and save any pieces that could help with restoration down the line. Most claims require you to immediately notify the carrier of damage and provide the documented “proof of loss” within a specific time frame. Before doing so, reach out to your insurance broker who can help guide you through this process.

Another best practice is addressing any damage in a timely manner to avoid any issues that could worsen with time or additional weather events. Taking immediate action, such as covering an exposed roof, securing doors and windows, removing water, and drying out any affected areas, can lessen the potential impact of further deterioration and keep those in the vicinity safe from harm. For more dangerous and technical issues, like getting the electric system back up and running, consult a qualified professional.

While hurricanes can certainly be daunting, there are ways to prepare in advance to make sure you are not caught off guard or without a plan. Be sure to assess your risk and execute the appropriate steps to protect your business, property and employees. Most importantly, lean on your insurance broker and other qualified vendors with any questions or concerns.

Earth Day 2020: What Does Climate Change Mean for Risk Management?

On Earth Day 2020, risk professionals can reflect on ways to protect both the environment and their businesses. Worldwide, climate change poses countless risks, including increasing the frequency and magnitude of natural disasters, reducing access to resources and disrupting supply chains.

To celebrate Earth Day and help risk management professionals address environmental risks and climate change, here is a roundup of some of our coverage from the past year about these critical topics:

From Risk Management Magazine:

Aligning Sustainability and Risk Management: A collaborative approach between sustainability and ERM can best drive real change.

Taking Action on Climate Change: As the potentially devastating impacts of climate change become clear, risk managers must assess the resulting risk exposures and ­opportunities for their companies.

Insurers Divest from Coal Over Climate Risks: Insurers are pulling coverage and investments related to the mining and use of coal.

Will Climate Change Impact Reinsurance Rates?: As natural disaster losses mount, the reinsurance response could spur action on climate change.

Getting Serious About ESG Risks: Investors are increasingly scrutinizing environmental, social and governance activity.

From the Risk Management Monitor blog:

Venice Sees Near-Record Flooding: The city of Venice, Italy, faced the worst flooding of its famous canals since the devastating floods of 1966, suffering major economic impacts.

Catastrophic Floods More Frequent in 2019: Major flooding has become a normal occurrence for many regions of the country, and by all indications, it is becoming worse each year.

Global Heat Waves Signal Climate Risks: The pattern of dangerous heat waves has become a yearly occurrence across the globe. 

Texas Study Shows Business Impact of Major Storms: The large storms hitting the coast of Texas are having serious impacts on industries across the state and country.

Limit Organizational Exposure During the Polar Vortex: Tips for protecting businesses during the frigid weather phenomenon.

Managing Coronavirus Business Interruptions

The novel coronavirus 2019-nCoV, now called COVID-19, has continued to spread through China and beyond, with more than 1,800 deaths reported as of this writing. The virus’s spread has also had major impacts on business operations around the world, slowing or shuttering international companies’ operations in China and prompting travel restrictions and evacuations.

Businesses around the world are taking travel precautions and creating or updating existing response plans to address these risks. Dr. Adrian Hyzler, chief medical officer of healthcare, assistance and risk management company Healix, told the RIMScast podcast that “Companies have to think on their feet and have crisis meetings, twice, sometimes three times a week just to try and keep up with the changes in government regulations and what they have to do to try and manage the situation.”

But companies may not be able to manage all of the issues resulting from COVID-19-related business interruptions, and some may even fail to fulfill their contractual obligations because of supply chain complications, risking severe penalties. If this occurs, companies throughout the supply chain have options for protecting themselves or recovering from lost business.

If contracts allow, companies may attempt to invoke force majeur clauses, which, according to international law firm Reed Smith, “excuse a party’s performance of a contract if an unforeseen event beyond its control prevents performance.” To prepare for these complications, Reed Smith recommends that companies:

  • review their contracts to determine what, if any, rights and remedies they have as a result of the delayed performance of contracts due to force majeure; 
  • provide timely notice of a force majeure event; 
  • prepare for potential litigation concerning failure-to-supply issues and the application of force majeure clauses, including by taking (and documenting) reasonable steps to mitigate the impact of the novel coronavirus; 
  • update form force majeure clauses to take into account, to the extent possible, modern risks to contractual performance, including diseases, epidemics or quarantines.

Reed Smith also noted that if a company intends use a force majeur clause to avoid financial penalties for business interruptions as a result of COVID-19, they should “take (and document) reasonable steps to mitigate the impact of the novel coronavirus. While these steps may prove futile, they are essential predicates to mounting a valid force majeure defense.”

There may also be insurance options for covering COVID-19-related losses. When speaking with the RIMScast podcast, Reed Smith’s Richard P. Lewis said that depending on a company’s exposures, some options for covering losses include contingent business interruption coverage, event cancellation policy, supply chain insurance or travel insurance. But, Lewis said, “The first big category would be first party insurance. That would be property insurance and more specifically a first party or property insurance policies providing ‘time element coverage’ that is impacted by time, usually known as business income or business interruption insurance.”

Lewis also said while property (like a factory that is shut down after the outbreak) may not have suffered actual physical damage, there could be legal precedent for claiming physical loss or damage “if the building can’t be used for its intended purpose.” Anderson Kill P.C.’s Finley T. Harckham also noted that in case law, people becoming sick on a property will not count as property damage, but contaminants at a property (including pathogens like COVID-19) could qualify.

U.S. companies, Lewis said, will be dealing with “contingent exposures, meaning the property affected is their customers’ or suppliers’ and not their own property.” However, if those companies have their own property, coverage is likely dependent on whether it was “closed by the order of a civil authority because of the actual presence of a virus and not the suspected presence of a virus.” Harckham noted that these restrictions would likely trigger civil authority coverage, which many insurance policies contain.

However companies attempt to cover their losses, Lewis recommended “Just make sure that if if this thing goes to court that you’re able to prove your losses. And that means to document them and to have witnesses who are able to explain what it is you lost and be able to testify at trial with that if it comes to that.”

To hear the full conversations with Hyzler and Lewis, listen to the RIMScast episode “What Risk Professionals Should Know About the Coronoavirus” here.