Insurance claims processing is without a doubt the final frontier on which most health insurance battles are fought.
The need for the right insurance partner is never as pronounced as during claim settlement. Smart enterprises in the insurance ecosystem realize this fact and put their best people in the claims processing vertical, says Susheel Agarwal, Founder & Director, Ethika Insurance Brokers Pvt. Ltd.
 
While Susheel always understood the importance of the claims processing vertical, one episode changed his perspective radically. He saw his good friend Jay burn his fingers during a claims experience and swear off the health insurance industry. And Jay is a financially literate upper middle-class salaried guy, Susheel tells us. He works for a Tier I technology service firm. Jay understands risk and is adequately insured.
 
Here’s what happened
 
Jay’s wife was undergoing a planned hysterectomy. Cautious that Jay was, he had called the office of the Insurer beforehand and checked with them as to whether the procedure would be covered. Once he had gotten a go ahead, he checked with the Third Party Administrator (TPA) for a good hospital where he could avail of a cashless facility.
 
Despite this, it had been about three hours since his wife’s admission and his request for cashless had still not been honored. Frustrated, he decided to walk into the office of the Insurer.
Once there, he was pushed from one desk to another. Finally, he found himself sitting in front of an old fellow, who seemed to be the decision-maker.
 
Just when Jay thought this would be the end of his troubles, the old fellow coughed “Your wife’s last name doesn’t seem to have been updated in your policy after marriage?”. Jay had lost it by now, not only was that not the case - he and his wife happened to share similar last names - Jay had been at the Insurer’s office for a good hour now and he did not see his misery ending.
 
Jay started lambasting the old fellow. When he was doing that, someone from the cabin in the office walked out. He seemed calm and composed and asked Jay about the matter. Jay narrated his entire story to this gentleman, hoping that maybe he could help. The man asked Jay to drop him a mail about the issue and he would get back to him ASAP. When Jay asked about the timeline for ASAP, he was given a curt tomorrow.
Jay decided to pay out of pocket and file for reimbursement.
 
Imagine, Susheel exclaims, this is the plight of an urban, upper-middle-class, financially literate individual. What might an average Joe be suffering?
 
At Ethika, Susheel built on this foundation.
Ethika's Customer Support rests on a three-legged stool, each one as important as the other.
 
Quality of Support

While most companies use technology to automate phone calls, Ethika uses it to enhance the quality of service. Most information is available to Ethika personnel at fingertips.
Once we have the name of the insured, our reps get all the required information through our proprietary software, says Susheel.
The median number of iterations between the Client and Ethika’s team is around 2 and the number doesn't go over 3. They also keep fine-tuning on the quality metric every quarter.
 
Immediacy of Suppor

Ethika probably has the widest list of questions that patient attendants would need to be answered from time to time, during a hospitalization. All of this information is available to their support team at fingertips. Even when something comes to them out of the blue, they know who would be the exact person who could answer the concern. This saves them time, the most critical element during hospitalizations.
We understand and value our clients' time, says Susheel. Since inception, we have been tracking the amount of time processes take and averaging these figures out. This helps us in giving clients a realistic estimate.
 
Brevity of Support

The last escalation I got was sometime in April, Susheel says proudly. Ethika has an authority matrix that specifies the kind and extent of authority one has over decision-making. This ensures decisions are taken in a flash. We do understand and appreciate System 1 & 2 thinking, Susheel adds, and I think we have a good handle on it.
 
But how does one objectively measure any of these three parameters?
To that, Susheel has a broad grin - well my Customer retention rate is above 97%.
That is as objective as one could get.

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