Insurance Industry Overview:
Insurance is a contract binding an insurance company to compensate a beneficiary for the loss of life or loss or damage to property of a person insured. Benefits accrue due to an individual due to statutory obligation of the benefit provider to compensate for the expenses involved in health care, retirement plans of the beneficiaries by entering into a contract with the provider either singly or in groups by paying a predetermined premium at predetermined intervals.
The process of Insurance and Benefit Management Business can be grouped under three main categories. These are Products, Processes and People.
A. Publicity and Promotion of Products
- Insurance and Benefit Product Vendors offer Perennial as well as Plan Year Based Products.
- The Promotional Materials including Application Forms for Perennial Products should be made available on the Client's Website.
- Upon requests form individual, the CRM staff should be capable of dispatching hard copies by Surface Mail.
- Insurance Agents also canvass for Products and their management for a specified Commission amount. The details of Agents are held in the database.
- Insurance and Benefit Vendors also promote their Products through brokers for Corporate Clients on a specified brokerage. The details of brokers and Corporate Client Information are to be stored in the database.
- For the Year Based Benefit Plans, the Promotional Materials and Application Forms are obtained from Vendors in advance and dispatched prior to the beginning of Plan Year. Corporate Client may employ it's own representative or use the services of Broker or Agent for bulk enrollment. The materials are dispatched either through Bulk Email or by Surface mail as convenient to the Client. For the Individuals and Groups who wish to enroll or continue for the Year Based Benefit plans the promotional materials and application Forms are sent as per their requirement.
- Enrollment Management Staff is responsible for collection and dispatch of promotional materials, maintenance of the concerned web page(s), receipt and approval of Applications, maintenance of master data of Plans.
B. Product Evaluation
- The selection of Products for promotion and management depends on the business yield, the popularity of the Product with benefits, the reliability of Vendors, the business relationship with the Vendors, legal and statutory requirements.
- To have an objective analysis of the Products, the Program will be using statistical tools to analyze the data on Plans, Premiums, Claims, Revenue Flows and Revenue earned.
- To gauge the relative effectiveness of the Vendors, the lead-time for Claims Adjustment, Rejections, Net Rebate Earned, the total number of beneficiaries will be given by the program
- The Enrollment Management will select the appropriate Vendors and Products in the best interest of the business and Clients for promotion.
C. Enrollment of Beneficiaries for the Plan
D. Receipts & Accounting of Premium
- Applications for Enrollment in the Insurance / Benefit Plans will be obtained through
b) Surface Mail
c) Bulk enrollment through:
d) Client Representative.
e) Its Own Representative.
- The data will be entered individually, where needed and validated through validation program for accuracy and completeness.
- The approved list will update in the Master list of affected tables.
- The rejected list will be sent to the applicant / the forwarding agency for resubmission or rejection.
- Where the applications are received through Internet, a confirmation letter will be sent to the Applicant on hard copy for his /her authentication and return. The Plan becomes effective only after the receipt of the signed copy.
E. Processing and Settlement of Claims
- Premium may be received from Individual Beneficiary through Check, Demand Drafts, Money Order, Pay Order or Credit or Debit Card Authorization.
- Corporate Clients may send the details of Premium Cutting as a separate file or as part of their combined Pay Roll.
- Groups may send their Premium Payments through a separate file.
- There will be a necessity to Import the above into the master files of the legacy database as each Client/ Group may have their own established data formats.
- Import definitions for each of the Clients / Groups should be customized.
- The Imported data will be reconciled for short, missing, invalid or overpayment against actual due and the Client notified accordingly.
- After reconciliation, the premium payment will update individual running ledger entry.
- Individuals prefer Claims against Products.
- These are required to be settled by the Carriers as per the entitlement.
- Claims are validated by Program as well as by the Claims Staff who are trained Claims Settlers.
- The Program does the validation for Effectiveness of the Claim, limits of liability.
- The Settlers verify authenticity of the Beneficiary and the supporting documents. In case of Life, Property and Vehicle Insurance legal documents may be required to authenticate the claim and the claimant.
- Once the Claim is processed, it is passed for Payment or Rejected.
- The Payment Order would be generated and sent to the Beneficiary or the Rejection slip with reasons.
F. Payments Processing and Settlement of Accounts with Vendors
G. Payments processing and Settlement of accounts with Agents/ Brokers
- The records should be updated and prefer a claim on the Vendor. Based on the business relationship with the Vendor, reimbursement of the Claims passed will be by book adjustment against Vendor Payment or Imprest Account.
- Then generate Payment advice, Payment Orders and Control Reports as per the needs of the management as well as Vendors.
- Similarly when Premium Payments are received from Individuals, Groups and Corporate Clients by Carriers, the Processing Staff will calculate the amount payable to Vendors for their plans and credit the amount to the Vendor. They will also generate required reports for the information of Vendors.
H. Routine and Exception Reporting for Management Control
- The Agents / Brokers / TPA's canvass for enrollment into Insurance and Benefit Products. The commission amount to Agents / Brokers / TPA's will be paid as per business rules and agreements. This may be fixed or based on a percentage of Premium amount. The periodicity of payment may be either onetime or periodic.
- The Brokers can make use of a custom developed software to promote both Software & Insurance / Benefit Providers for soliciting their Products. The software would calculate the amount due to Agents/ Brokers / TPA's to cater for all types of payments. It will also Generate Pay orders, update Accounts and print needed control and information reports.
- Reports are required to have control on the activities outlined in each of the above processes. These reports will help the management for decision-making.
- Ready reckoned for calculating Premium amount, commission and brokerage for different plans will be made.
- There will also be a list of FAQ's for use by Management, Agents / Brokers / TPA's, Individual beneficiary, Clients and Staff.
I. Customer Relationship Management
J. Accounting and Audit
- This process would enhance the relationship between Management, Staff, Agents / Brokers / TPA’s, Beneficiaries, Groups, Clients, Vendors.
- The concerned departments of Carrier would be responsible for maintenance and updating of Information pertaining to CRM activities.
- This process [CRM] includes Call / Request Registration, Call / Request Tracking and Call / Request Closure.
- Control Reports will be generated for Pending, Open and Closed Calls / Request.
- The amount received as Premium will be validated against the expected and exception report will be generated for each client and plan.
- The amount paid against Commission and brokerage will be based on type of payment and periodicity.
- The amount due to Individual beneficiary will be based on Service charges to the Client and the rebate from the Carrier.
- Carriers will carry out audit on percentage of approved and rejected Claims manually at random and an audit report will be made.
- The payment dues towards service charges and rebate will be credited to Corporate Accounting.
- The Commission and Brokerage will be calculated for payments to Agents and brokers.
- The Premium Payments to Vendors will be calculated and payments made/ adjusted.
- Receipts and Acknowledgements will be sent through appropriate media.
- Summary and Individual Reports will be generated as needed by the Management