Today, I will talk to you about claim investigation.
1. What will be strictly investigated when making claims?
I have written many articles about sickness insurance before, and I have always emphasized the importance of telling the truth. But whether to tell the truth or conceal the medical history depends entirely on everyone's integrity.
Even if a friend conceals his health status and takes out insurance, the insurance company will not immediately investigate his medical information.
A large number of people buy insurance every day. It is an international practice not to investigate medical records when taking out insurance. This can save the cost of insurance companies, design products with better premiums, improve the user experience, and enable consumers to apply for insurance conveniently and quickly to achieve a win-win situation.
In addition to the above reasons, there is also a rule why insurance companies don't have to investigate customers:
Article 16 of the Insurance Law stipulates that if the insured intentionally fails to fulfill the obligation of telling the truth, the insurer shall not be liable for compensation or payment of the insurance premium for the insurance accident that occurred before the termination of the contract, nor shall it refund the insurance premium.
However, due to greater autonomy, it will inevitably give some dishonest policyholders an opportunity. Therefore, when applying for claims, the insurance company will intervene in the investigation of the case in order to verify the authenticity of the accident. Insurance companies will be extra vigilant if they encounter the following four situations:
1. 1 The claim amount is high.
Insurance companies will be highly vigilant against cases with relatively high compensation and will handle them in special circumstances. We will also examine customers' insurance motives from the perspective of financial liabilities.
1.2 The insurance time is too concentrated.
If a person has never bought insurance before and suddenly buys a lot of high-value insurance in a short period of time, especially those who are responsible for death, then most insurance companies will check the behavior and motivation of this person to buy insurance, and various insurance companies will also inform each other.
1.3 Apply for claim settlement soon after insurance.
It doesn't take long to file a claim, especially if you file a claim just after the waiting period. Insurance companies need to rule out the possibility of taking out insurance against illness, so the investigation will be relatively careful.
1.4 claim frequency is too frequent.
Medical insurance has the characteristics of high frequency and low loss. If claims are frequently made during the insurance period, even in the case of medical abuse, insurance companies will pay special attention to such situations when making claims to prevent fraudulent insurance.
Generally speaking, the insurance company has a serious review and recheck process, and the insurance company will give sufficient reasons for whether to pay for each case.
2. How did the insurance company conduct the investigation?
At present, according to the actual situation of each case, insurance companies can investigate personal information such as medical records through the following channels:
The following focuses on the three main investigation methods of insurance companies:
2. 1 medical record
Obtaining the medical records of the insured through the medical insurance card has become the most important investigation method for insurance companies. The medical insurance card records the information of hospitalization, outpatient service and drug purchase in detail, which can be considered as the basis of the holder's past medical history.
In addition, Yuan Jun Jun also solemnly reminded everyone not to lend their medical insurance cards to others at will. If the medical insurance card has a drug purchase record related to serious diseases (such as hypertension), it may become a hidden danger of underwriting and claims settlement.
2.2 Medical records of medical institutions
Some friends will think, if I don't need a medical insurance card, is there no record to check?
Of course not. Medical insurance records ≠ medical records.
Medical responsibility can be traced back. Investigators of insurance companies will comprehensively analyze and judge whether customers are healthy before insurance according to basic information such as medical records, chief complaints, medical records, treatment and doctor's advice.
General hospitals are written in accordance with the requirements of the National Health and Family Planning Commission. In addition to the basic information of customers, there are also course records, nursing records, doctor's advice records and so on. As an objective reflection of the patient's condition, these records confirm and restrict each other. If one record is changed, other records usually have to be changed accordingly.
Moreover, electronic medical records have been implemented in China, and outpatient medical records are kept for not less than 15 years, and inpatient medical records are kept for not less than 30 years. These cases recorded the patient's information in detail, and the records confirmed each other, which often affected the whole body. This further restricts insurance fraud.
Before, a doctor concealed his past illness, and his wife was the agent of the insurance company. By tampering with medical records, the two men insured millions of critical illness insurance in more than ten insurance companies in an attempt to cheat insurance, but in the end, the case was solved under the joint investigation of many insurance companies, public security economic investigation and doctors' associations.
Moreover, future medical records can be completely "permanently" saved.
It should also be emphasized that the "medical institutions" mentioned here include general hospitals, specialized hospitals, community hospitals, township hospitals (stations), maternal and child health stations, etc. This is allowed in all countries, except "small".
2.3 Record of Inter-bank Claims
In fact, the investigators of various insurance companies need what the other party needs, and the past claims records of the insured can be retrieved through the ID card, which is also a common method.
In addition to the above investigation channels, insurance companies can entrust claims investigation to relevant outsourcing investigation and evaluation companies, including but not limited to hospitals, physical examination centers, disease control centers, health bureaus, social security bureaus, peers and other networks. Through these ways and means, we can basically verify every claim settlement case and put an end to insurance fraud. Some people may be worse. My medical record is personal. Without my consent, is the insurance company qualified to check them? In fact, we granted this right to the insurance company when we took out the insurance, but you didn't notice these details:
It can also be seen through authorization that the scope of investigation and evidence collection by insurance companies is unlimited, as long as relevant evidence can be provided, it is the scope of investigation and evidence collection by insurance companies.
3. Recovery of claim investigation cases
Through a real case-just after the waiting period, I will take you back to the whole process of the insurance company's claim investigation, and play it back as follows:
The insured is an employee of a pharmaceutical company in Hangzhou. Just after waiting for 90 days for 500,000 critical illness insurance, he submitted the breast cancer diagnosis medical record to the insurance company and applied for a claim.
Insurance company survey process:
The insurance company went to Zhejiang No.1 Hospital to check the medical records and found that the insured had a lump in his left breast six months ago and refused to be hospitalized.
I took the medical records from the Fourth Hospital of the city and found that he had a B-ultrasound examination before insurance. The records showed that the left breast occupied a space.
The insurance company then sent a claim adjuster to interview the customer. The client said that she suddenly found a lump in her breast when she took a shower two years ago, but she went to the hospital for examination but didn't get treatment. The claimant immediately went to his company to try to obtain medical reports for the past few years, but was told that the customer had never attended the company's medical examination. Finally, the adjuster visited the nearby hospitals, health service stations, community hospitals and family planning institutes, and visited the director of the Women's Federation of the neighborhood committee.
After the above-mentioned on-site claims investigation, the insurance company concluded that the customer concealed his medical history when he insured, and the policy had just come into effect for half a year, and the period of non-defense had not expired, so he made a claim conclusion of canceling the contract and refusing to pay.
This is a typical case of applying for compensation just after the waiting period. During the investigation, the insurance company will use all channels to verify the medical conditions before insurance. With the networking of national medical insurance, medical records will be easier to find in the future, so it is very necessary to tell the truth.
4. How do insurance companies manage risks?
As we mentioned earlier, the reason why insurance companies don't do pre-insurance research is that insurance companies are not completely out of control before insurance.
In the past, insurance companies identified risks by means of health inquiry and underwriting. In addition, they also made some investigations on customers with extremely high insurance coverage, such as requiring the designated medical examination items and submitting financial certificates, and set up some operations similar to deductibles.
For the part that has not been truthfully informed and the risk of fraud, at this time, insurance companies generally adopt big data risk control systems to eliminate large risks in advance.
4. 1 What is the risk control system?
The risk control system is comprehensively scored based on health, occupation, behavior, finance, credit reporting and other dimensions. Those who do not meet the requirements will be detained and cannot be insured. It's a bit like the qualification exam for bank loans. First, evaluate your education, job, RV, etc. Finally, decide whether to lend or mortgage.
The risk control system is like a gate, embedded between insurance companies and customers, and analyzes potential risks by screening the big data of policyholders.
Taking Everbright as an example, its risk control system mainly gives comprehensive scores from four dimensions: health data, medical treatment behavior, internet behavior and insurance claim data: if the score is abnormal, the system will automatically refuse insurance.
So where did these evaluation data come from?
On the one hand, insurance companies have a set of informal channels to share high-risk information. For example, if someone buys multiple accident insurances from multiple companies in a short period of time, or is suspected of fraudulent insurance in the past, then his information will be synchronized to other insurance companies soon.
On the other hand, technology giants such as Alibaba Cloud, Tencent Cloud and Baidu Cloud will also provide risk control services.
We don't know what data these internet platforms collect or how they will use our data. But on the whole, our lives are getting less and less private.
4.2 What about "controllable risks"
At present, the existing big data risk control system is not particularly mature, and it is inevitable that there will be "accidental injury".
For example, many friends recently asked me: I insured a product, although it clearly met the conditions of occupational scope and health notification, but I was told that I failed to pass the risk control audit and could not be insured.
Maybe you don't have a big problem yourself, but the interception conditions of the insurance company's risk control model are a bit broad, or there are some problems with the collected data, and finally it is intercepted inexplicably. At this time, I suggested:
(1) You can directly change a company's insurance. Big data risk control is similar to smart underwriting and will not leave a record of refusal;
2 complaints. At present, individual products have issued risk control rules calling for a green channel. If you are intercepted by the wind, you can apply for a complaint.
In short, the most direct impact of the application of big data risk control is that insurance is getting harder and harder to buy.
But in the long run, the ultimate benefit is our consumers themselves, because big data reduces the adverse selection cost of fraudulent insurance or sickness insurance, so relatively speaking, ordinary consumers do not have to pay for the adverse selection cost, and the overall insurance rate may also come down.
This is the content of the insurance company's claim investigation. In my opinion, the purpose of buying insurance is to get a guarantee, not malicious deception. Only by telling the truth, being honest and obeying the rules can we avoid claims disputes; Once there is a risk, you can also get a claim quickly and really use it in an emergency.