The Malaysian Insurance Institute (MII), the leading professional body and education institution for the local insurance industry today held its 9th annual International Claims Convention (ICC) with the theme ‘Insurance Claims Management in the New Age’. The ICC is being held at Impiana Hotel KLCC Kuala Lumpur, from 20 – 21 March, and have attracted over 100 industry professionals and key players who discussed topical issues of the day and looked at new approaches to claims management in the new age.

Yang Berusaha Mr Antony Lee, Chief Executive Officer of AIG Malaysia Insurance Berhad who delivered his Special Address on, Measures Initiated by PIAM to Support and Reduce Insurance Claims in Malaysia at the convention. Also present to officiate the event was The Malaysian Insurance Institute’s Chairperson, Yang Berusaha Ms. Anusha Thavarajah.

The two-day convention has looked at the changing environment that brought the unpredictable challenges to the insurance industry in managing claims. The topics delivered have incorporated perspectives from both domestic and regional contexts. This 9th International Claims Convention focused on real-life case studies and lessons learned.

The stage has been set for a great line-up of presenters such as Walid H. Jishi of ALA Group, Francois Metzler of ACCENTURE, Uma Devi Nadarajan of Ombudsman for Financial Services, Prof. Allan Manning of The LMI Group, Carliff Rizal Carleel of Chatbot Malaysia, Priya Pillai of Niru & Co LLC, Hima Bindu of Swiss Reinsurance Co Ltd, Dato’ Dr. Rajbans Singh of Beacon Laureate, Syed Ahmad Fuqaha of Katsana Holdings Sdn Bhd, Liam Kok Chye of MATCOR Technology & Services Pte Ltd, Dr. Kamalanathan Sappani of Eximus Medical Administration Sdn Bhd, and Stuart Pack of Medical Opinion Asia Sdn Bhd.

 

Speaker Presentations & Highlights

International Claims Conventions 2019 has passed, and we would like to share some of the highlights and presentations by few speakers who have given insights in the two-day convention.
SAFER ROADS TOGETHER by Mr Aiman Auni of KATSANA

Malaysians are bad drivers

• 6^th HIGHEST CAR THEFT IN THE WORLD
• 18^th HIGHEST ROAD FATALITIES IN THE WORLD
• 60 vehicles are stolen every day in Malaysia.
• 20 road deaths daily in Malaysia

KATSANA signs MOUs With Axiata and major Motor Insurance firms to boost adoption of usage – insurance in Malaysia.

 

Between the year 2004 and 2013, there has been a death of 65,850 people due to road accidents. It resulted in as much as USD20 billion lost in potential economic contributions to the nation.

 

MEDICAL NEGLIGENCE IN SINGAPORE by Niru & Co LLC Advocates & Solicitors

Presentation Outline

1. The Law

2. Disciplinary Hearings / Civil Claims

3. Procedure & Protocols

• State Court
• High Court
• An Alternative Approach

4. Recent Developments

The Bolam Test

• The Bolam Test derived from Bolam v Friern Hospital Management Committee [1957] 1 WLR 582.
• The test for the standard of care expected of a professional practicing a special skill is that of an “…ordinary skilled man exercising and professing to have that special skill.”
• The test merely requires that the accused doctor show that a body of other doctors professing the same skill or expertise would have acted in the same way.

 

The Montgomery Test

• Previously, the Bolam Test applied to every aspect of the patient-doctor interaction – most of the time there was little need to distinguish between diagnosis, advice and treatment.
• The Montgomery Test is derived from Montgomery v Lanarkshire Health Board [2015] UKSC 11 and applies to medical advice.
• A doctor must disclose material risks as well as reasonable alternatives to the recommended treatment.
• Material risks are defined as those which a reasonable person in the patient’s position would likely find significant, or that the doctor should reasonably be aware that the patient would find significant.
• It comes down to patient autonomy.

The Montgomery Test in Singapore

• In Hii Chii Kok v Ooi Peng Jin London Lucien [2017] SGCA 38, the Singapore Court of Appeal held that the Bolam Test now applies only when it is alleged that a doctor negligently diagnosed or treated a patient.
• Where there is an allegation of negligence in advising a patient, the Montgomery Test applies.
• The test focuses on the patient’s perspective and unlike Bolam, the views of other doctors are not determinative.

The test, has the following stages:
1st Stage – Relevant and material information from the patient’s perspective.
2nd Stage – Did the doctor have the information?
3rd Stage – If the doctor was in possession of the information, to determine the reasons why the doctor chose to withhold the information from the patient. Burden is now on the doctor.

 

State Courts/High Courts & Procedure/Protocols

Whether it be the State Courts or the High Court, there are strict procedures and protocols that are in place for medical negligence claims, which must be followed.  In most instances, medical professionals/bodies are defended by their insurers.

An Alternative Approach

• Multiple number of reasons for the attractiveness of an alternative approach to litigation.
• Most common are mediation and neutral evaluation.

A Gentler Approach: Mechanisms In Play

Towards a less adversarial approach:

• Healthcare Mediation Scheme: Mediation services offered at subsidized rates.
• State Courts Centre for Dispute Resolution
• Supreme Court’s introduction of ‘pre-action disclosure of documents’ and “ADR Offer”
• Mediation Act
• Establishment of the Singapore International Mediation Centre and the Singapore International Mediation Institute

CAPITALIZING ON TRULY DISRUPTIVE CLAIMS SERVICES: Winning the Wallets of your Customers in a Liberalized Market by Rudolf Frei

In Insurance Business, Boring Equals Profitable?

Pluto’s property and casual business is stable and, to be honest, quite boring. That is a good thing because in insurance business, boring equals profitable.

At the heart of a profitable insurance business is the risk assessment and pricing, i.e. underwriting.

That is what we are good at – or as Apollo Zulu, the CEO and President, says: “We are insurance nerds”.

The insurance industry is the boring uncle of the financial services family.

By contrast, banking conjures up colourful images of Wolf of Wall Street excess, which has helped to fuel a healthy dose of scrutiny….

Excelling in traditional claims services is not good enough

Strategic Differentiator: Claims Services

Traditional Claims Services

Insurers’ default solution of delivering claims services is quite simple:

• Let lawyers discover the meaning of terms and conditions
• Adjudicate claims in accordance with the coverage enshrined in policies
• Settle claims reasonably quick

Satisfied and dissatisfied Customers walk away

The Crux of this technical service approach means that it is not engaging or electrifying customers – it is no fun dealing with insurers’ claims services.

 

FAIR CLAIMS HANDLING PRACTICES WARRANTS KNOWLEDGE IN VARIOUS DISCIPLINES by Mr Walid of Arab Loss Adjusters

The implications commonly associated with claims handling stems from the subjective approach “Why we have to pay” rather than “Why we don’t have to pay”

• If the Insured is in breach of a warranty or insuring clause, the objective approach is to differentiate between affirmative and promissory

INFLUENCING FACTORS

1. Compliance
2. Breach

WARRANTIES

Warranties are either affirmative or promissory. Affirmative, tend to imply that a fact exists at a given time but not necessarily continue to exist or observed throughout the insurance period. Promissory, the fact exists and continue to exist and observed through out the insurance period.

The questions that would arise

1. Was there a causal relationship between the breach and operating peril?
2. Did the breach contribute to the extent of loss?
3. Was the breach a willful negligence of deliberate nature committed by whom? (the Insured or employee serving the Insured?)

Breach of duty of care by the Insured or his/her servants do not void the policy of insurance nor give right of rejection UNLESS it is of deliberate nature committed by the insured or at his/her directions and embrace a criminal act.

Referring to some technical warranties and clauses in both property and engineering that are commonly used and misinterpreted in the course of determining policy liability in property and engineering contracts.

1. No smoking warranty
2. Conditions concerning fire fighting facilities and fire safety
3. Safety measure with respect to precipitation, flood and inundation
4. Warranty concerning construction material
5. Warranty concerning camps and stores
6. Conditions Regarding Offsite Storage

IDENTIFYING THE OPERATIVE PERILS

Natural Perils

• Earthquake
• Fire or natural origin
• Flood
• Hail
• Landslide/ mudslide
• Lightning
• Static electricity
• Temperature extremes
• Tidal waves
• Volcanic Eruption
• Wind (hurricane, tornado, typhoon, tempest)

Human Perils

• Arson
• Chemical leakage
• Contamination
• Electrical overload
• Explosion
• Fire and smoke
• Human error
• Radioactive contamination
• Riot
• Sabotage
• Strikes terrorism
• Theft, forgery, fraud,
• Toppling of high-piles objects
• Vandalism, malicious mischief
• Vibration
• War

Economic Perils

• Change in consumer taste
• Currency fluctuation
• Depreciation
• Expropriation confiscation
• Inflation
• Obsolescence
• Recession
• Stock market decline
• Technological advances

CRITICAL ASPECT

Commonly, insurance policies rarely incorporate Loss Locating Cost. (i.e. expenses incurred to locate the cause of damage which is not usually covered under standard policies unless by extension)

FRAUDULANT CLAIMS

If any claim under or on this Policy be in any respect fraudulent or if any fraudulent means or devices are used by the Insured or anyone acting on his behalf under this Policy or if the loss, destruction or damage be occasioned by the willful act or with the connivance of the Insured, all benefits under this Policy shall be forfeited.

AREAS

1. Living insurances:- Medical, Life, Travel
2. Motor vehicles and equipment insurance
3. Bodily injury – T.P liability, employer liability, product liability, business and commercial –arson, trade, fraud
4. Maritime –Hull & Cargo
5. Professional practices, stock & insurance brokers, accountants, physicians
6. E-commerce & credit cards
7. every other Insurable risk

ANTI-FRAUD PRACTICE – WHY?

• Insurance embraces every aspect of our life, it has become a “must” not a “need”
• It shields our economic prosperity at personal, and organizational level
• It is a partnership between the insuring public and the insuring bodies. Every “YUAN” taken feloniously affects the wider consumer base, not nationwide, but globally
• Fraud mitigation is thus, not a commercial aspect as much as a social responsibility

FINANCIAL CRIME – L/C, the horse of troy

1. Buyer and seller are the same party or in accomplice.
2. Gross exaggeration of cost of sale
3. Load containers with products of no value.
4. Load Pre-damaged cargo OR Forge shipping documents –B/L
5. L/C enchased upon submission of documents
6. Goods abandoned upon arrival and L/C money not honoured.
7. Insurance claim filed by beneficiary Bank.
8. Litigation commence.

The implications with letters of credit are their documentary nature, the opening and negotiating banks are only concerned with the documents which on the face of it should appear correct without discrepancies. i.e. not concerned with the physical delivery or conformity.

CARGO – Containers, the Horse of Troy

• FCL containers provide a platform for cargo insurance fraudulent claims.
• The shipper loads the cargo and seals the container.
• Carrier endorse B/L “said to contain”,” shippers load”,” stow and count”.
• Buyer and shipper are either the same party trading under different titles or an accomplice.
• Container seal may be tempered with either in the port of loading, or on the ship, or upon arrival to imply short delivery or intentional change of cargo during transit.
• Pre – shipment damaged goods loaded to claim for goods of no value, customary in such situation, the price is grossly overstated in the contract of sale.

Investigation should emphasize:

1. The Insured owes a duty of care to the third party.
2. There is careless breach of that duty (negligence).
3. There is injury or death sustained by the third party.
4. There is causal relationship between the breach and the injury.

The industry will continue to be confronted with fraudulent claims and abuse. Whatever the loss prevention precautions are, the notion of guilty until proven innocent approach constrains the Investigation process.

Frequently, reinsurers elect to engage foreign adjusters not familiar with the laws and regulations nor the business culture of the country THUS Claims cooperation clause warrants mutual understanding of the mechanism by which cooperation is deployed.

References – Speakers Presentation from International Claims Convention (ICC2019)

• SAFER ROADS TOGETHER by Mr Aiman Auni of KATSANA
• MEDICAL NEGLIGENCE IN SINGAPORE by Niru & Co LLC Advocates & Solicitors
• CAPITALIZING ON TRULY DISRUPTIVE CLAIMS SERVICES: Winning the Wallets of your Customers in a Liberalized Market by Rudolf Frei
• FAIR CLAIMS HANDLING PRACTICES WARRANTS KNOWLEDGE IN VARIOUS DISCIPLINES by Mr Walid of Arab Loss Adjusters