Meeting insurance companies, we have seen that handling medical assessments for personal claims can differ a lot between different companies. Here we share the three most common approaches and point out some pros and cons to each setup.

1. Internal Medical Advisors

The Medical Advisors are employed by the insurance company and work closely with the claims adjusters, sometimes even sitting just a desk away.

Pros:

  • The claims adjusters learn a lot about medical questions and easily ask follow-up questions and discuss the case.

 Cons:

  • The claims adjuster might influence the Advisor in how to assess the case.
  • The Medical Advisors get compensated by the insurance company, which might question their objectivity.
  • It is almost impossible to internally have all medical expertise, resulting in more general assessments and problems with second opinions.

2. Freelancing Medical Advisors

Another common way is to hire medical advisors as freelance consultancies.

Pros:

  • This approach could possibly broaden the areas of expertise if you contract several consultants on a need-to-have basis

Cons:

  • The Medical Advisors often use, for example, Gmail or Outlook for communicating extremely sensitive information, which could lead to a privacy breach.
  • It can be time-consuming to recruit and maintain an extensive network of advisors to cover all disciplines.
  • Quite often, there’s no structured process for sending requests to the Advisor, and without an overview of the material – a lot of time is wasted on administrative tasks – which delays the case
  • It doesn’t eliminate the credibility issue regarding objectivity.

3. Licensed DSS with Medical Advice

A third common approach is to handle medical assessments through a licensed DSS with access to a network of independent Medical Advisors.

Pros:

  • The advisors have no direct connection to the insurance company and are often randomly assigned each case to ensure that they are non-biased.
  • The assessments are made through a structured process in the DSS, ensuring quality control.
  • The network often includes all medical disciplines enabling quality assessments and second opinions.
  • The insurance company saves a lot of time, not having to recruit and maintain the network themselves.

Cons:

  • It might include a license cost for the DSS system.
  • The medical advisors will not work as closely with the claims adjuster so they can learn from them.

Those are the three-set up’s we have identified. How do you work? Any other pros and cons you think we have missed? Please let us know.