Question

We consider the following process for handling claims for disability insurance at a insurance company called InsureIT. When a claim is received, a junior claims officer first enters the claim details into the insurance information system and performs a basic checks. Next, the claim is moved to a senior claims officer who performs an in-depth assessment of the reported disability and estimates the monthly benefit entitlement (i.e. how much monthly compensation is the claimant entitled to, and for what period of time).

In the case of short-term disability benefits, the senior claims handler can perform the benefit assessment without requiring further documentation and notifies the customer of the outcome via e-mail or postal mail.

In the case of long-term disability claims (more than three months), the senior claims handler requires a full medical report in order to assess the benefit entitlements. The process for obtaining the medical report is explained below. Once the senior claims handler has received the medical report, they can assess the benefits entitlement. The senior claims handler then notifies the customer of the outcome of the assessment and their monthly entitlement if applicable. The decision is recorded in the insurance information system.

In case a claim gives rise to an entitelement, a finance officer triggers the first entitlement payment manually and schedules the monthly entitlement for subsequent months.

When a medical report is required, a junior claims handler contacts the customer (by phone or e-mail) to notify them that their claim is being assessed, and to ask the customer to send a signed form authorizing InsureIT to request medical reports from their health provider.

Once the authorization has been received, the junior claims handler sends (by post) a request for medical reports to the health provider together with the insurer's letter of authorization. Hospitals reply to InsureIT either by post or in some cases via e-mail.

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