"Communications Pack Group Insurance Claims AXA Australia Financial Protection Contents"
Communications Pack Group Insurance Claims AXA Australia Financial Protection 2007 Contents • Introduction • Centres of Excellence • Group Claims Structure & Team Set Up • AXA Claims Management • Benefits of the New Structure • Claims Management Model • TPD Definitions • Procedural Fairness • Service Standards • Disputes Resolution • Our Strengths • Case Studies 2 Introduction The purpose of this pack is to provide you with an overview of the Group Insurance Claims Structure at AXA in 2007. A review of the Group Insurance Claims structure was undertaken in early 2006 with a view to improve on AXA’s Group Insurance Claims structure. It was envisaged that the changes made would allow us to better meet our client’s needs and expectations, whilst providing a more efficient, well- organised and improved internal structure and processes for staff. The following slides will provide further detail around our structure. 3 Centres of Excellence Wellington Melbourne Sydney Individual Individual IP IP NZ Group AXA Insurance AXA and AC&L & Group Lump Sum Insurance NZ Individual IP & Lump Sum AC&L NZ 4 Group Claims Structure 3 Teams with a Focus on Group Insurance Claims • 2 Teams focusing on the assessment of Group GSC and TPD products • 1 Team focusing on the assessment of Individual Lump Sum & SUMMIT products. • - GSC & TPD Teams: Fund Split file allocation - Individual Life Team: Alpha Split file allocation • The Administration team • Eligibility assessment is handled by Group Portfolio Administration and is currently managed by Geoffrey Grace. • The Claims Team works in conjunction with Group Portfolio Administration to help minimise delays in the assessment process 5 Team Set Up Team A Team B Team C GSC & TPD GSC & TPD Individual Lump Sum & SUMMIT Manager: Jeri Thomas Manager: Mark Grapel Manager: Michael Todd Lead Assessor: Lead Assessor: Lead Assessor: Sabrina Beekmeyer Rupert Butterworth Orpheus Polioudakis Assessors: Assessors: Senior Assessor: Gordon Papworth John Hickey Sam George Fiona La Greca Mary-Anne Dunn Suzanne Ryan Livio Basile Assessors: Anne Newell Margaret Molloy Jim Velaoras Geoffrey Chan Sam Illardo Linda Gentilin Katharina Stojakovic Angie Myers Gokhan Akyol Liz Cooper Tim Lumsden Rosamaria Calabretta Anthony De-Lellis Soo Drake Sabrina Jeremiah Rudy Westley Sandra Martin Ognjenka Trogrlic Luke Moulton Barry Carr Contact List provided with Handouts 6 AXA Claims Management It is our business to pay genuine claims. We aim to keep our clients fully informed throughout the course of the claim. We will comply with legislation affecting claims management. Claims will be assessed fairly and sensibly based on medical and other relevant evidence using consistent guidelines and procedures. Each claim will be thoroughly evaluated on the terms and conditions of the contract and the information provided. We strive to work with our clients to achieve a successful return to work. We make our best efforts to minimise payment of fraudulent and illegitimate claims. 7 Benefits Of The Current Structure Meets our customers’ expectations Facilitates flexibility Uses AXA’s successful “IP Model” as a benchmark Each Fund has a dedicated and knowledgeable team managing their portfolio Cross training within the teams - multi skilling Uniformity & Consistency in culture and philosophy Knowledge sharing within each team Always looking to improve 8 The Claims Management Model 5 Point Method of Assessment 1. Medical 2. Rehabilitation 3. Financial 4. Legal 5. Investigations It is a holistic assessment model and a decision is made strictly using the Terms and Conditions of the policy Differences in assessing GSC and TPD There are support services integral to the assessment model – eg Specialist Panel 9 TPD Definitions Unable To Work In Own Occupation Test is to form a view on all the available evidence whether or not the member has the capacity to return to work in their pre-disability occupation with consideration to education, training and experience. Unable To Work In Any Occupation Test is to form a view on all the available evidence whether or not the member has the capacity to return to work in any occupation that they are suited to with due respect to education, training and experience. 10 TPD Definitions Unlikely To Work In Own Occupation Test involves forming a view on all the available evidence whether the member can return to work in their pre-disability occupation with consideration to education, training and experience and also focusing on the likely availability of work to the member with the given disability and considering that if such work was available, whether it is likely that the member could access it. Unlikely To Work In Any Occupation Test involves forming a view on all the available evidence whether the member can return to work in any occupation with due respect to their education, training and experience and also focusing on the likely availability of work to the member with the given disability and considering that if such work was available, whether it is likely that the member could access it. 11 Procedural Fairness Procedural Fairness stems from Beverley v Tyndall and it applies as courts have decided that insurers have a duty, as part of the duty of good faith, to: 1) Give to the claimant the material relevant to the claim that the member may not have seen which is adverse to the member's claim and 2) Give them an opportunity to respond to that adverse material and 3) AXA must consider that response, if it is given, before any decision is made on the claim. The material to be provided includes medical reports, witness statements and employer records as well as anything else adverse to the claimant’s claim. AXA is obliged to forward this material onto the client directly - if we pass it to a third party and it does not (in full) get to the client then AXA may be deemed to be in breach. In short, the trustees are not a party to the insurers procedural fairness process obligation. In cases where AXA believe that self harm is a concern - we pass the material onto the client's treating doctor for release to the client. 12 Service Standards Group Life, TPD Claims and Group Salary Continuance Policy owner / intermediary Claim Advise of ineligibility Provision of additional Advise of decision notification assessment decision information Group Insurance Admin Receive claim and image document to system No Construct claim file and Eligible? conduct eligibility check Yes No No Claim Sufficient Yes Claim Allocate to assessor assessment Information? accepted? No further action AXA Claims Yes Payment calculation No Ongoing GSC Payment made claims? Yes Indicative timeline Life & TPD: Confirm eligibility to claim Claim assessment Payment made within 2 - 4 working days 3 - 5 working days after receipt of all 5 - 7 working days after GSC: requirements receipt of all information Payment made 3rd to 5th working day of each month 13 Disputes Resolution Internal Complaint – any stated or implied expression of dissatisfaction with a decision, service or product Primary Complaint – any complaint received from a member, Trustee or any other person other than a dispute resolution scheme (ie. FICS/SCT) or regulatory body Specialised complaints resolution section Complies with the requirements set out by ASIC for internal dispute resolution Case conference mandatory where the original decision reviewed Response to the complaint within 45 days (FICS) or 90 days (SCT) Resolved without the need for litigation 14 Disputes Resolution External Secondary Complaint – where a complaint is received from a dispute resolution scheme (ie. FICS/SCT) or regulatory body Occurs where complaint is not resolved to the persons satisfaction at the Primary Complaint stage Can also occur where the Primary Complaint was not dealt with within the time allowed Case conference where original decision reviewed Conciliation If not resolved at Conciliation, the determination is eventually made by the dispute resolution scheme AXA is bound by the determination. 15 Our Strengths Fair and sensible claims decision making Transparency of file management Clear and open communication to relevant parties Ability to consistently meet service standards Timely and accurate gathering of information Accuracy in the assessment process Early intervention and rehabilitation Team work, compassion and empathy 16