Recently, Xinhua News Agency and other media have widely reported that a retired cadre in Harbin was hospitalized for two and a half months, spending more than 5 million yuan (recently upgraded to tens of millions of yuan), and finally could not escape the bizarre situation. The series of reports on medical expenses have once again made us shudder at the phenomenon of arbitrary charges by domestic medical institutions.

At the same time, Guangdong and other places use professional adjusters with medical background and medical clinical experience to intervene in the hospitalization process of the insured to reasonably prevent and control medical expenses and shorten the time limit for insurance claims. The case allows us to feel the progress of market behavior.

The insurance adjuster walked to the front desk

The winter night came very early. One night a few days ago, Mr. Zhang's newly purchased car accidentally had a serious collision in his community due to slippery roads after dark. An anxious Mr. Zhang immediately found the insurance company’s phone number to report the incident, for fear of delaying the claim settlement. As a newbie on the road, although it was his first time to have an accident, he often heard relatives and friends around him complain that the insurance company had too many things to do and it was difficult to settle claims, which made him a little uneasy. Ten minutes later, his phone rang, and the other party explained the purpose of his visit: "We are the adjuster company commissioned by Tianping Insurance. We will arrive at the door of your community in 40 minutes to conduct an on-site inspection of your vehicle collision and make a determination." Damage, please cooperate when the time comes. ?

?The insurance adjuster will come to inspect and assess the loss for me? No one from the insurance company will come? ?This is the first time Mr. Zhang has heard of such a thing. He then called his friend who worked in an insurance agency who applied for car insurance. The agent told him that the Tianping car insurance he insured was a new company with a new model, so the vehicle inspection and damage assessment work was handed over to several insurance adjusters. As the process continues, the insurance company itself does not have an independent claims verification department.

No coincidence. Ms. Liu from Shenzhen is a life insurance and medical insurance customer of the local Pacific Life Insurance Company. She was recently admitted to the hospital due to acute pancreatitis. After reporting the case to the insurance company, she did not expect to be greeted by an adjuster from Shenzhen Mintai'an Appraisal Company. personnel, as well as the flowers and greetings they brought. The public adjuster also told Ms. Liu’s family that an imported drug the doctor planned to use was not covered by the medical insurance they purchased. There was also an alternative domestic drug that could be reimbursed. Which drug should be used? Please tell the family Decide.

The market is booming? Professional loss assessment account?

Do these scenes in the insurance claims process feel very fresh? Insurance companies are out of sight, replaced by insurance adjusters.

In fact, with the refinement and development of the market division of labor, professional insurance loss adjustment companies, especially specialized auto insurance and health and medical insurance adjustment companies, have emerged.

Tianping Automobile Insurance Company, headquartered in Shanghai, officially started its business in April this year. As the first professional automobile insurance company in China, Tianping followed the successful international model and pioneered the "two-end distribution outsourcing" model: the front-end marketing was changed to agents and brokerage companies; all loss determination and compensation in the back-end claims system were outsourced to adjusters. OK, please ask a law firm to participate in the aftermath. Although some insurance companies have entrusted loss assessment services to loss assessment agencies in the past, these were mostly cases involving disputes or cases with high technical requirements. The overall outsourcing of Tianping Auto Insurance is the first in China. Cai Xinyi, deputy general manager of the investment planning department of Tianping Insurance, told reporters that as of the end of October this year, Tianping Auto's premium income was only more than 9 million yuan, but by the end of November, this number had quickly soared to more than 17 million yuan. The increase was fierce. The company internally predicts that sales will surge in December, and the effects of the brand and new model will begin to emerge. Moreover, Tianping’s average car insurance premium is always at a relatively high level in the country, which shows the quality of its policies.

In the south, the Shenzhen Special Economic Zone has a developed insurance market. Shenzhen Mintai'an Insurance Adjustment Co., Ltd., the leader in the national adjustment and adjustment industry, established Mintai'an Automobile Insurance Adjustment and Adjustment Co., Ltd. in 2003. At the end of October this year, the first professional company in China to engage in medical and health insurance adjustment and adjustment business, Shenzhen Mintai'an Medical and Health Insurance Adjustment and Adjustment Co., Ltd., was established. When this new accounting firm opened, it signed cooperation agreements with the Shenzhen branches of Pacific Life Insurance, Taiping Insurance, and Yong'an Insurance.

With the emergence of the unconventional behaviors of these two institutions, it can be predicted that public accountants, who have traditionally worked mostly for large property insurance companies, will enter more and more homes of "ordinary people" in the future.

Illustration link:

General auto insurance claims process:

Auto insurance accident - report - insurance company determines loss - both parties agree - agree - pay claim< /p>

- Disagreement - Dispute occurs - Agreement adjustment and settlement

- If negotiation cannot be reached, find a third party for coordination, ask for a public estimate or an arbitration award, or file a lawsuit in court?

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The auto insurance claims process in which the adjuster participates:

Auto insurance accident - report - loss assessment by the adjuster - approval - insurance company pays the claim?

General health and medical insurance Claims settlement process:

An accident occurs - report the case - collect the materials required for claim settlement after discharge and submit them to the insurance company - the insurance company evaluates and determines the result

-agree - pay the claim

- Disagreement - Dispute occurs - Agreement adjustment and settlement

- If negotiation cannot be reached, find a third party to resolve?

The basic process of health and medical insurance involved in the adjustment and adjustment:

When an accident occurs - report the case - contact the patient and medical institution in a timely manner - assist the patient and the hospital in determining the medical plan - report the progress to the insurance company to speed up the claim settlement - pay the claim immediately after discharge

There are many benefits to early intervention of the adjuster

As we all know, in the Chinese insurance market, insurance companies have always been in a relatively proactive position, and the insured is in a passive position most of the time. Once a claim needs to be settled, the insured uses his personal power to cooperate with the company. In competition, it is easy to suffer losses. But at the same time, policyholders often falsely report and exaggerate the amount of losses during claims settlement. Some researchers believe that the insured's over-reporting behavior in claims is inevitable. Even in Western countries with developed insurance industries, the over-reporting rate is It is also as high as more than 90%. ?As consumers, everyone has the subconscious tendency to exaggerate losses. ?

Cases of a damaged car that has not been repaired for three or four months due to the inability of the two parties to coordinate the price of the damage have frequently been reported. Medical insurance claims disputes are even more common. There are endless cases of car insurance and medical insurance fraud, and news about insurance companies refusing or reluctant to pay compensation is also common.

Ever since, a problem has arisen. The status of the two parties in the claim settlement is unequal, and most of the time the information is asymmetric, which turns into an embarrassing situation of mutual distrust between the two parties. To use an economic term, both parties in the insurance buying and selling market are trapped in a "prisoner's dilemma" and can only engage in game wars with each other. Claim settlement is difficult, time-consuming, labor-intensive and inefficient, which has become a criticism in the market. In the long run, this is bad for the insurance industry and bad for the consumer industry.

If there is a third party that is independent of the insurance company and the insured, and it can judge and define the behavior of both parties, the market situation may be much better. If the same problem is handled by a third party, it may get twice the result with half the effort. This role is that of an insurance adjuster.

From the above diagram of the claims settlement process, we can see that the early intervention of the adjuster has many benefits. First of all, the direct intervention of a professional third party is helpful to eliminate the long-term accumulated distrust between the policy holder and the insurance company, making it easier for the policy holder to accept it psychologically. Secondly, the direct friction between policyholders and insurance companies is reduced, and the claims settlement process is shortened, which alleviates the old problems of multiple claim settlement disputes and long claim settlement time to a certain extent, thereby improving the efficiency and quality of claims settlement services. The "medical control intervention" of health and medical insurance adjusters can reduce the financial pressure of policyholders to a certain extent.