PVZP: insurance claims assessment and processing

Publikováno: 12. 9. 2023
Autor: Vladimír Pulchart
Foto: Shutterstock.com
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The insurance claims assessment department at VZP Insurance (PVZP) is a division charged with the assessment and processing of claims reported by insurees. This department is a crucial part of the operations of every insurance company and one of its key functions. A properly managed claims assessment department is vital to ensure client satisfaction and good financial results for the business.

It's not all about numbers and compensation amounts, however, as it also helps maintain a long-term relationship and trust with the client in conjunction with product departments and sales representatives. An insurance company actually works in reverse – if you buy a product in a store, you get the value out of it right away. In an insurance company, you purchase a product first but only get to really appreciate its importance when an adverse event that is covered by the insurance policy occurs.

Increasing knowledge requirements
Claims assessment processes work essentially the same way they have for decades, and the work of all true claims assessment experts is anchored in trusted procedures. It may seem at first that the processing of a claim is a routine and simple process. However, some types of claims that have started appearing recently are rather different, such as those related to cybersecurity risks and professional liability, primarily in terms of medical care, vehicle insurance, etc. These are some of the fields that are growing ever more complex and require a higher level of expertise to ensure responsible processing, even from external contractors such as assessors and expert witnesses. Simply put, no two instances of damages are the same and each one requires an individual approach. What's more, insurance companies often face fraudulent claims, which need to be identified and separated from those of honest clients. That creates an additional need for specialists who deal with such cases.

Patients and doctors
In recent years, we have observed a growing trend here at PVZP of claims for damages caused during treatment in various medical facilities. It's not just about the growing number of said claims but also their individual component parts and the corresponding payouts. Patients often come to healthcare facilities with certain expectations as to how their ailments will be treated, or rather cured, and they expect no other results than a full recovery. This sometimes leads to situations where patients may consider complications that arise during treatment, or a final outcome that differs from their expectations, to be an instance of not receiving the best possible treatment even though they were made aware of potential risks before the initiation of the treatment or the operation via the so-called informed consent to medical treatment. When complications arise, patients naturally look to the medical staff for liability. However, the claims brought against medical facilities are often made without any expert assessment, especially when it comes to the level of compensation sought. Unfortunately, we also often deal with cases where the claim is backed up by an expert assessment, but the medical treatment is evaluated retrospectively (ex-post) rather than prospectively (ex-ante). Simply put – the matter to be assessed is whether the physician made the correct decision and conducted themselves accordingly in a given situation, meaning that they acted according to the rules of science and implemented good medical practices (lege artis). The matter then often ends up in court and it is up to the judiciary to decide the legitimacy of the claim.

Post-operative conditions
Another issue are claims made in cases of surgical procedures where patients were previously afflicted by various long-term chronic diseases. In such cases, the pre-existing condition can sometimes deteriorate, especially if it is a complex surgery with a longer period of subsequent treatment. Cases where complications related to prior health conditions are attributed to the medical facility that conducted the surgical procedure are, unfortunately, also quite frequent, and proving causality (or lack thereof) is often protracted and complicated. Even these cases are mostly solved in court.

Additional non-economic damages
The so-called additional non-economic damages are a chapter unto themselves, and they are covered in essentially all cases similar to pain, suffering, and loss of amenity claims. The specific cases in which non-economic damages claims can be applied are gradually being outlined by the judiciary. It will clearly stipulate that a certain level of discomfort, stress, or difficulty connected to the sustained bodily harm – if it relates to standard levels of pain – must be compensated under the general category of pain and suffering. Therefore, certain levels of discomfort caused by hospitalization, loss of autonomy, fear of medical treatment, etc., cannot be considered additional non-economic damages.

Preventing costly proceedings
There is a shortage of experts capable of classifying additional non-economic damages, which is a major issue right now. Doctors are not interested in this activity for various reasons, and a number of quality experts are slowing down or leaving the field entirely. This is not an issue for just insurance companies but also for the police force and courts. There could be serious issues ahead for this field which might end up requiring systemic solutions because expert assessment is a crucial aspect of judicial decision-making for numerous institutions.
Naturally, we also process legitimate claims because errors do happen in the course of medical treatment, sometimes, sadly, with fatal results. In such cases, we employ considerable efforts to assess and process the claim as soon as possible while working closely with both the medical facility and the claimants to prevent protracted and costly court proceedings and to ensure that they are adequately compensated for the damages suffered.
A comparison with foreign countries is worth noting here. A large part of the general public in Czechia still believes that the damages awarded in Western European countries are immeasurably higher than those available domestically, but the opposite is true. Non-economic damages are evaluated based on the individual circumstances of the case and the claimant, and the final compensation usually reaches tens of thousands of euros at most.

PVZP is a universal health insurance company that offers insurance plans covering everything from health, through family and property, all the way to entrepreneurial activities. PVZP has 25 years of experience with health insurance and is irreplaceable in this regard.
It is historically the first insurance company to cover medical expenses as part of travel insurance plans and was previously the only insurance company with knowledge and expertise in the field of foreigner health insurance. PVZP currently holds a significant share of the market in relation to property insurance and the liability insurance of healthcare institutions, contractual doctors, and pharmacists. Other insurance products offered by PVZP are statutory car insurance, vehicle insurance, citizen's liability and property insurance, accident insurance, serious medical condition insurance, and entrepreneurial risk insurance.
An interesting fact about PVZP is that it is the only insurance company on the market that funnels funds back to the national budget because the General Health Insurance Company of the Czech Republic is its sole shareholder. That makes it the only insurance company protecting public finances.
Additional information about PVZP can be found at www.pvzp.cz.

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