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5 Best Practices for Effective Claims Reviews

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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.

Responding to Litigation Hold Notices

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The purpose of a litigation hold is to preserve relevant information when an organization reasonably believes this information can lead to an investigation or litigation. The information to be preserved can be documents, equipment and/or electronic information or materials that may be relevant to a lawsuit or an investigation, depending on your industry. If relevant documents or information are lost, altered or destroyed, the company could suffer serious legal consequences.

The spoliation of evidence is “the intentional, reckless, or negligent withholding, hiding, altering, fabricating, or destroying of evidence relevant to a legal proceeding.” The maximum penalty for destroying or concealing evidence is either six months in a county jail or a fine up to $1,000, or both. For example, spoliation can occur when documents are shredded, emails erased, physical evidence is sold, destroyed or hidden and otherwise rendered unavailable for trial. It is the company’s duty to take all reasonable steps to preserve potentially relevant information.

The risk professional’s role is vital—he or she may be aware of an incident that might give rise to a claim or suit, well before a suit is filed, sometimes even a year or more. For example, if you receive an incident report that a third-party vendor fell on your property, you would call security to see if there is video of the incident, and if so, secure a copy of that video. You would interview any witnesses, preferably on the day of the event while memories are fresh, and document the incident in their words. If the victim alleges that something caused the fall, then you should take photos of location and determine whether the pavement was wet or dry, there was debris in the aisle, what the weather conditions were, and other considerations. Once you complete the investigation, all documentation should be stored and secured.

If there is a claim that is either in a lawsuit or the company believes could later become a lawsuit, the clock starts ticking on litigation hold notices. In the United States, the law requires that companies comply with their duty to preserve evidence. Evidence is broad and can include an automobile involved in an accident; emails; a chair involved in a slip and fall; videos, voicemail, photographs or text messages; among others. The notice can involve official company files, personal files or non-official files. All information that may be relevant to the matter must be preserved.

Preserving potential evidence that the company believes may reasonably lead to a lawsuit or investigation takes a coordinated effort that can involve legal, risk management, IT, HR, compliance, engineering, security and any other department.

If you are an employee who may have information pertinent to investigation or lawsuit, you would be considered the custodian of this information and would have a legal obligation to preserve such evidence. As custodian, the legal department or possibly a third-party administrator would instruct you to preserve the evidence. The general procedure is that you would receive a notice on a matter that could be involved in an investigation or a lawsuit. You will be required to review, comply, sign and certify a document that states you agree to preserve information that would be related to the event. There may be a requirement to return signed document within a certain amount of time from receipt, and violation may result in disciplinary action that can include termination.

The evidence required may be very specific (such as video recorded on this date), or general (like all related emails), and may include a date range. Once identified, do not destroy, alter, modify or delete documents subject to the hold notice. When the lawsuit or investigation is completed you will receive a termination and release of this obligation. The evidence may be saved as part of the company record retention program.

Risk management can play an important role in this process by storing the hold notice in the claim file, periodically reminding custodians of their obligations, involving and sending new notices for new custodians that might have evidentiary material, and notifying custodians of termination of hold notices.

Staying Safe During the Holidays

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Whether in the office or at home, everyone needs to be extra careful and alert during the holidays. Because people are trying to pack so much into their day, accidents can happen.

At home, Allstate cautions to be alert to fire hazards, which can lead to substantial losses.

The LiVe Well Intermountain Trauma Managers Group lists some steps that can be taken to promote a safe environment:

Avoid Falls

  1. Keep sidewalks, driveways and entrances free of snow and ice. Falling on icy sidewalks is the number one cause for visits to the emergency department. Use sand or ice melt to prevent slipping.
  2. Falls while putting up lights and decorations is another. Do not use stools or chairs for hard-to-reach areas. Rather, use a sturdy ladder and have additional help.
  3. Ensure that your office or home is free from items that may cause people to trip or stumble, especially around a Christmas tree or other decorations with extension cords and light strands.

Safety Checks

  1. Check your furnace. It should be cleaned and checked regularly by professionals.
  2. Inspect fireplaces for safe operations. Use a screen or glass front, never leave a fireplace unattended and don’t burn gift wrappings, tissue, or evergreens in the fireplace.
  3. Make sure circuits are not overloaded.
  4. Check cords and plugs for wear, frayed insulation, cracks, and loose connections.
  5. Place a tree away from heat sources and open flames. Check the lights before placing them on the tree. Look for loose sockets or broken and frayed wires.
  6. Turn lights off when you leave.
  7. Never use a regular string of lights on a metal tree. The danger of shock is great. Rather, use a spotlight to illuminate a metal tree.

Holiday Driving

  1. Allow extra time for heavy traffic and poor weather conditions.
  2. Be courteous and respect the rights of pedestrians and other drivers.
  3. Be on the look-out for inebriated drivers.
  4. Expect the unexpected from pedestrians carrying large holiday packages.