Data Management, Claims and Complaints

Data management, claims and complaints

Topics covered

1. Data management

2. Claims management

3. Complaints management

4. Data management

• An insurer must have an effective data management framework that allows the insurer at
  all times to:
  o have access to data that is up-to-date, accurate, reliable, secure and complete; o properly identify, assess, measure and manage the conduct of business risks; o comply with all relevant legislation relating to confidentiality, privacy, security and retention of data; o comply with any regulatory reporting requirements; o assess its liabilities under each policy; o adequately categorize, record and report complaints; o have access to any other prescribed data. Conduct of business returns, information requests etc.

Data management cont.

• At the minimum an insurer must have:
  o names; o identity numbers; o and contact numbers of all policyholders.
• Contact details must be as complete as possible and where available include mobile
  number and e-mail address of the policyholder.
• Outsourced data processing...insurer must be able to access such data at any time as and
  when required by the insurer.

Data management cont.
Source: https://i0.wp.com/timoelliott.com/blog/wp-content/uploads/2018/02/data-is-the-new-oil-toxic-if-mishandled.jpg?ssl=1 How do you make informed decisions without data????

2. Claims management

• Insurer must establish, maintain and operate adequate an effective claims management
  framework.
• The framework must be:
  o proportionate to nature, scale and complexity; o be appropriate for business model, policies, services, policyholders and beneficiaries; o allow claims to be assessed…after reasonable steps to gather and investigate all relevant and appropriate information; o not impose unreasonable post sale-barriers to claimants.
• The framework has to consider the Rules relating to the time periods for assessment of
  microinsurance and funeral claims.

Claims management cont.
The claims management framework must at the least provide for:

• Proper allocation of responsibilities;
• Appropriate performance standards and remuneration and reward strategies;
• Documented claims “end-to-end” process with time-frames;
• Process for interest payment for delayed claims;
• Proper record keeping, monitoring, analysis and reporting to executive & board;
• Appropriate communication with claimants and their authorised representatives;
• Compliance programme to combat fraud and money laundering appropriate to insurer’s
  exposure and vulnerabilities.

Claims management cont.
Prohibited claims practices:

• Dissuading claimant from using attorney or adjuster;
• Denying claim without conducting reasonable investigation;
• Denying claim solely due to outcome of polygraph, lie detector, truth verification or similar
  tests.

3. Complaints management

• Insurer must establish, maintain and operate adequate an effective complaints
  management framework.
• The framework must be:
  o proportionate to nature, scale and complexity; o be appropriate for business model, policies etc.; o allow complaints to be considered…after reasonable steps to gather and investigate all relevant and appropriate information; o not impose unreasonable post sale-barriers to complainants.

Complaints management cont.
The complaints management framework must provide for:

• Proper allocation of responsibilities;
• Appropriate performance standards and remuneration strategies;
• Documented complaints management process;
• Proper escalation, decision-making and oversight;
• Proper record keeping, monitoring, analysis and reporting to executive & board;
• Communication with complainants and their authorised representatives;
• Engagements with the relevant ombud;
• Process of managing complaints relating to service providers.

Complaints management cont.
At a minimum the “complaints register” must include the following categories:
o the design of a policy or related service, including the premiums or other etc; o information provided to policyholders; o advice; o policy performance; o service to policyholders, including complaints relating to premium collection or lapsing of policies; o policy accessibility, changes or switches; o complaints handling; o insurance risk claims, including non-payment of claims; and o other complaints.

Complaints management cont.
Data fields to be maintained on complaints:
o number received; o number upheld; o rejected and reasons for the rejection; o escalated by complainants to internal complaints escalation process; o referred to an ombud and their outcome; o number and amounts of compensation payments made; o number and amounts of goodwill payments made; and o number of complaints outstanding.

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