Medical claims review in an emerging market.
Traditionally, insurance medicine has made significant contributions to sound underwriting and to the rise of insurer's margin of risk ratio. However, it is may be less effective in emerging markets, because emerging markets have few clinical follow-up studies, and there is a lack of medicoactuarial research. Making a medical expert's opinion to insurance claim administration is called a medical claims review. It is subdivided into medical verification and advice for claims staff. In addition to medical risk selection, it is a new field of insurance medicine in emerging insurance markets, which are often characterized by assertive insurance consumers. Medical contributions at the stage of claims adjudication compare the coverage provided in the product, with the information provided in the claims, based on medical records and the agreement between them. This is called medical verification. The insurance doctors can also use their medical knowledge to help the claim staff with informing claimants about the medical basis of claim decisions.
SIS Insurance Claim Adjustment Co Ltd, 10th Fl. Samsung-Jeil Bldg. 702-2, Yeoksam-Dong, Gangnam-Gu, Seoul, Korea. drlee@sisko.co.kr
Sinhyung
S
Lee
D006801:Humans; D007343:Insurance Carriers; D007345:Insurance Claim Review; D007348:Insurance, Health; D007723:Korea; D012308:Risk Management / Q000379:methods