Health & Benefits Blog
A claim is an unexpected event that can lead to a financial burden both for the employee as well as for the employer. A claim can be an accident or an illness. When a claim occurs, certain steps must be taken to obtain financial compensation and to avoid potential legal consequences.
Occurrence of a claim (illness / accident) - What to do?
Claims processing is an important part of the insurance business. It is therefore even more important to know how to proceed in the event of a claim, what needs to be done when, and what points need to be considered. In this regard there are obligations on the part of both the employee and the employer.
Insured person:
The insured person, in this case the employee, is obliged to immediately notify the employer of an accident or illness in case it requires medical treatment and/or results in a disability to work.
Furthermore, the insured person must cooperate with the insurer. For example, he or she has to sign a power of attorney, make the registration for the disability insurance (IV) and he or she must be available for medically ordered examinations by the insurer.
Policyholders:
The policyholder, in this case the employer, is obliged to notify the insurer within a reasonable time of an accident or case of illness.
But why is a notification in a timely manner that central? The sooner the insurer is informed of a case of illness or accident, the faster it is possible for them to intervene and to help mitigate the damage.
Further, this enables them to better calculate the costs that will incur and if necessary to quicker pay out the benefits for the policyholder.
The deadlines to notify a case, are basically specified in the general terms and conditions of the contract and they can vary from insurer to insurer. However, in most cases, the notification of a claim is expected within 30 days.
What happens in the event of a late notification? The consequences of the failure to comply with these deadlines are again specified in the general terms and conditions of the contract and vary from insurer to insurer. But basically, the insurers may entitle themselves to reduction or denial of benefits if the policyholder fails to comply with obligations in the event of a claim.
What tools are available for the notification of a claim?
Filling out forms, managing absences and recording benefit claims. Various tools are available to your HR department to report claims as easily and efficiently as possible.
Due to the digitalization more and more online tools for reporting a claim have emerged in recent years. Probably the best known is called "Sunet Plus". "Sunet Plus" can be installed directly on the computer. This way, the HR department can be supported in the management of accidents and illnesses. Thanks to its user-friendly structure and simple functions, work can be done more efficiently and with fewer errors. "Sunet Plus" is aimed at companies with a salary sum of CHF 2 million or more or at least 10-15 claims per year.
Another common tool, which is also aimed at smaller companies, is "BBT-Claims". Just like "Sunet Plus", it enables the policyholder to report claims easily and efficiently and subsequently process them.
In addition, many insurers also offer the possibility to submit the claim online via their website - i.e., without any additional tool.
In addition to the claim’s notification process, there are other points which must be taken into account in the event of an illness or accident. Below you will find a useful checklist to support your HR department.
Disability insurance: when does an early registration make sense?
If a person with a health limitation loses his or her job or is excluded from the labour market, ailments often become chronic in a very short time. Therefore, it is crucial to intervene quickly and take countermeasures in case of impending disability or job loss.
Even before the official IV registration, there is the possibility of a notification for early registration. If a person has been incapacitated for work for a longer period (at least 30 days), if there are signs of a longer incapacity for work or if there are repeated short absences due to health reasons, it makes sense to register for an early assessment. The early assessment lasts about 30 days. During this time, the aim is to check whether the IV is responsible and to clarify whether the official registration is indicated. The notification for early registration may be made by various persons / institutions (e.g., employer, attending physician or family members living in the same household). However, it is important to note that the insured person must always be informed of this.
In contrast to the early registration, the official IV registration is an application to receive IV benefits. This notification must also be received by the responsible IV office as soon as possible, but no later than 180 days after the beginning of the incapacity for work. The punctual notification of an IV registration is generally also made by the insurer. However, if the notification is submitted late, certain benefits may be reduced.
The insured person, their legal representatives or third parties who regularly support the insured person can make the official IV-registration.
Which role takes WTW over in this process?
Our clients often are layman in the insurance sector and do not know how the procedure in case of a claim looks like. Often clients are glad for any support they receive in case of a claim.
Therefore, WTW assumes a supporting role in the event of a claim and offers high-quality expert support. We provide our customers with full support if they have any questions or uncertainties regarding claims. If there are difficulties in filling out the claim form or if there are problems with the payment of benefits by the insurer, we intervene as a third party and provide further assistance.
We ensure that all data processed in connection with claims handling is stored properly and in a way that prevents misuse or unlawful use. Personal injury claims usually involve data that is particularly worthy of protection, which is why the provisions of the Data Protection Act are especially important in these cases to protect the rights of those affected and ensure that their data is handled correctly and securely.
In exceptional cases, we are also more involved in claims processing. Doctors’ certificates are sent by the employees directly to WTW. We have an overview of all absences, report claims to the insurers as soon as necessary and check the daily allowance statements. We thus take over all the administrative activities that arise because of a claim.
