Receiving Complaints From Customers

Through the assessment, the insured can be advised on measures to minimize the consequences of the loss that has occurred and prevent future losses, helping the exploitation staff to better assess the risks before accepting insurance for services of a similar nature.

The insurance company must be responsible for assessing all losses that the customer reports to the company as quickly as possible. During the assessment process, to facilitate a quick and accurate assessment, the assessor must create an atmosphere of trust and cooperation, but absolutely must not make any commitments about the amount of payment or inform the customer about how to calculate the amount of payment to avoid the case where the customer provides incorrect information. The insured must be responsible for honestly and fully declaring the provisions in the insurance request and paying the correct and sufficient insurance premium according to the provisions of the insurance contract, honestly declaring and providing accurate documents about the insured risks that occur.

To have a more comprehensive view of the current status of appraisal work at PJICO, we will delve into the following specific activities:

2.1. Receiving complaints from customers

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In human insurance operations, to ensure benefits as well as help participants quickly stabilize financially, PJICO requires the insured or the person with insurance benefits to notify the company of a complaint as quickly as possible within a certain prescribed time limit when an insured event occurs.

Normally, the insured person must notify the insurance claim at the office or agency where the claim is paid. The notification can be done in many ways such as directly notifying, notifying in writing, telegram, fax, but the most common is notifying by phone for small and medium losses and directly meeting for large losses. In case of receiving information about a serious human accident, the officer receiving the information must notify the leader so that the superior can handle the situation. After receiving the customer's complaint notice, the compensation officer can find out information about the customer's level of damage, consider whether it is within the scope of the claim.

If the damage is determined to be not covered by insurance, the insured must be officially notified in writing with satisfactory explanations.

In human insurance business, the insured subjects are numerous and they often sign large contracts or in groups. Small contracts can range from 50-100 participants such as the Passenger Car Operator Enterprise (84 people), the Public Works and Transport Construction Company (154 people) to contracts with a relatively large number of participants such as student and teacher insurance contracts that can range from 400-600 people such as Tan Dinh Secondary School (573 people), Hai Ba Trung High School (452 people)... In particular, there is an insurance contract for thousands of employees of Honda Vietnam Company (4,475 people). The area of operation is very wide, so the information of complaints to insurance officers is often through agents. Usually, each unit participating in a large group like the above will have a representative to make a list of insurance money collection and will be responsible as an insurance agent, receiving commission. This agent can be the company's accountant or a medical staff at those units. When there is compensation, the insurance officer will guide the customer to complete all the necessary documents in the insurance file. The first thing is to get the customer's declaration of the risk that occurred through the declaration in the "Insurance claim form" provided by PJICO. According to the principle, the insured person is responsible for honestly and accurately declaring the insured risk that occurred, including name, address, date of accident, cause of accident (specific declaration, details of the accident...), consequences... This declaration must be confirmed by the school or the authorities where the accident occurred and the insured person or their representative must sign to confirm their declaration to serve the appraisal work.

Each set of personal insurance claim documents includes the following documents:

after:

1. Insurance claim form (with confirmation of occurrence)

2. Insurance certificate or copy of insurance participant list.

3. Medical documents: hospital admission and discharge papers, treatment forms, surgery forms (in case of surgery) and other relevant medical documents.

4. Hospital death certificate in case of death.

5. Certificate of legal inheritance rights.

6. Compensation settlement report.

7. Insurance receipt.

8. Insurance payment statement.

9. Accident report.

Upon request for PJICO to pay insurance money, the insured or beneficiary must send PJICO documents (1-5) within one month from the date the insured is cured or dies.

In case the insured and the beneficiary of the insurance money act dishonestly in declaring and collecting documents in the compensation file, PJICO has the right to review or coordinate with the competent authorities to resolve. Depending on the level of violation of the insured and the beneficiary of the insurance money, PJICO has the right to refuse part or all of the insurance money. In case the party shows signs of violating the law, PJICO is responsible for requesting the law enforcement agency to review and resolve.

Due to the large number of participants and the relatively good system of agents, the appraisers do not have to go directly to the scene for all cases but can coordinate with related units to create accident and illness records at the traffic police department, hospital, agency... that helps the company reduce some of the complexity due to travel, saving costs and communication time. At the same time, this also leads to the creation of fake and invalid records to claim compensation. Therefore, the presence of record verification work is needed.

2.2 Profile Verification

Check whether the documents are valid, complete and truthful. The appraiser must pay close attention to the cause of the accident. This is an important content and is carried out immediately when conducting the appraisal to determine the responsibility of the insurance company. Because the insured event is a risk that occurs to human health, the appraiser must have certain knowledge of medicine and pharmacy, experience, and sharp judgment to recognize whether the customer's behavior is insurance fraud or not? There are also many cases where PJICO's compensation officers cooperate with professional officers of a number of agencies to verify information such as police, doctors, engineers, etc.

To verify whether the customer's statement is truthful or not, the compensation officer can use many different methods to collect information: contacting the customer at the company, calling to interview or going directly to the place to examine the actual condition of the insured and grasp the information. In the past, at PJICO, there were many customer files that needed to be re-verified. In 2003, at Office I of the company alone, there were about 50 customer files that the appraisal officer had to go to the medical facility to check. For example, in the case of a Doan Ket secondary school student who had a file to claim compensation for himself when he had to be hospitalized and had surgery for his ears due to deafness. The compensation officer asked for a referral letter from the agency, went to the hospital - where the surgery was performed - to verify whether the student was born deaf or not. If he was born deaf, it would not be within the company's responsibility, otherwise the company would pay normally.

The method of implementation is entirely up to the appraiser to proactively choose to suit the actual situation, ensuring the verification of the records achieves the most accurate results. In general, the appraiser must always be aware of his/her responsibilities, must know how to work independently and scientifically, and know how to collect necessary information for the job. Because commercial insurance and personal insurance are industries with a large amount of work and a lot of traveling, from the beginning of exploiting customers until the contract expires, the above qualities are even more required of an appraiser.

Coming to PJICO's insurance department in region I, it is easy to see that the insurance staff are really dynamic, have a serious and reasonable working attitude. When there is a case

When there is a loss, the staff in the department divides the work among themselves to avoid the situation of many files being left behind at the same time. The appraisal work is carried out very flexibly, depending on each file and each insured object.

2.3 Check the completeness of the application

The claim officer works with the statistics and accounting department to re-check the insurance records. The re-checking of the records is to supplement all missing documents on the one hand, and to review the reasonableness and truthfulness of the above evidence on the other hand to avoid insurance fraud.

After completing the documents, the compensation officer will calculate the insurance payment for the customer.

General comments:

In general, appraisal activities in non-life insurance do not have clear differences between the operations because the insured events are risks related to human health, so the main documents used as the basis for considering insurance payments are all issued by hospitals. Therefore, when verifying documents, appraisal officers often have to go to medical facilities to re-examine the incident.

Particularly for 24/24 personal accident insurance and tourist insurance, in cases of suspected insurance fraud, the assessor must contact the traffic police to clarify the accident report before going to the hospital to verify. In cases of severe damage (tourist insurance), upon notification, the insurance officer must be present at the scene immediately to coordinate with other authorities to resolve the matter.

In addition, for the remaining insurance operations, the appraiser will have to contact agents at agencies and schools to verify the records.

Due to the complex and diverse nature of personal insurance operations, appraisal work at PJICO also faces many difficulties and limitations. The number of insurance participants is large and scattered. There are cases that occur in other provinces, far from branches and offices. According to regulations, customers participating in insurance will send

claim compensation there. The reality is that the agency team is almost not equipped with knowledge of medicine and pharmacy. Therefore, the initial assessment of the extent of damage is not accurate. Even the compensation officers are very vague about this issue, the assessment mainly relies on experience and senses. Moreover, the team of collaborators who are doctors and nurses is thin (the whole company has about 200 collaborators) and they do not always have time to assess or advise. Risks can happen anywhere, to anyone at any time... Some cases of assessment are therefore not strict, the assessment record is too sketchy to be used as a basis for compensation settlement. In addition, coordination with relevant units such as traffic police, hospitals, agencies, schools, etc. to establish accident records and medical records is still loose, leaving many loopholes for insurance fraud such as prolonging hospital stays, recording incorrect disability status or declaring death before the contract expires. For those who participate in insurance and have relatives working in the health sector, if there is insurance fraud or false declaration, compensation must still be resolved due to insufficient evidence. Because insurance fraud is a complex issue, it will be discussed in more detail in the following section.

To solve this problem, companies and offices must make appropriate investments as well as strengthen links with relevant units to improve the quality of appraisal work in the best way.

3. Compensation and insurance payment

As mentioned above, one of the factors that has brought PJICO from one success to another is the settlement of compensation (for hospital and surgical insurance and travel and passenger insurance), payment (in the remaining PNT insurance services) for customers quickly and satisfactorily. The concept of "not only purely a matter of financial compensation but also of concern and sharing the difficult situation when customers are unfortunately at risk" is that the compensation and payment of insurance money at PJICO is carried out quite well and has a direct and positive impact on the perception and psychological assessment of customers participating in insurance. Currently, PJICO is one of the three leading companies in Vietnam in the field of non-life insurance.

Once the personal insurance file is complete and valid, the compensation officer will calculate the amount to be paid to the customer based on the actual damage of the customer as well as the insurance contract that the customer has signed. In the context of fierce competition between insurers, to increase its advantage over competitors, PJICO has decentralized the handling of insurance events to units, ensuring flexibility and reducing inconvenience to customers. Specifically: if the payment or compensation amount is less than or equal to 5 million VND, the office will directly handle the file. And if it is greater than 5 million VND, the office will transfer it to the company for handling. If the file is still stuck, requires further explanation or the documents are not enough, the company will ask the office to work with the customer to complete the file. When the file is approved for insurance payment, the company will send an official dispatch to the office to notify the insured and proceed with the payment.

In the process of calculating the insurance benefit settlement plan, PJICO must comply with the prescribed principles of insurance payment consideration. For example, in comprehensive student insurance, the Ministry of Finance issues a table of disability insurance payment rates with the following principles:

Payment settlement according to the table will be based on the victim's treatment documents and the following regulations:

1. Normal treatment wound: without or with surgical costs, non-infected wound will pay insurance for this injury corresponding to the lowest level of the insurance payment scale prescribed in this case.

2. Complicated wound treatment: accompanied by major surgery requiring outpatient treatment at the hospital, infected wound, wound requiring suture or plaster cast or after treatment there are still sequelae, depending on the severity with inpatient or outpatient treatment time above the normal level in point 1 above, each day will be added 0.5% of the insurance amount but not exceeding the highest level of the insurance payment scale prescribed in this case.

3. In case of multiple injuries as specified in the table, insurance will be paid for each injury but the total amount paid to the insured person will not exceed the insurance amount.

4. For serious injuries specified in Part II of the insurance payment rate table (internal organs, heart, liver, lungs... or soft tissue injuries that crush the legs, arms, head or burn the whole body...) insurance payment will be considered based on the day of inpatient or outpatient treatment. Each day is equal to 0.4% of the insurance amount but cannot exceed the insurance amount.

In the hospital and surgical benefit insurance, when issuing the insurance payment rate table, the following principles for considering insurance payment are included:

1. The figures in the table above indicate the compensation that can be paid for the respective type of surgery and are expressed as a percentage of the sum insured.

In case of normal surgery, the wound is not infected and does not leave any post-operative sequelae, the insurance will be paid at the lowest level of the insurance payment scale prescribed for this type of surgery.

In case of complicated surgery, infected wound or post-operative sequelae, depending on the severity, the payment will gradually increase up to the maximum level of the insurance payment scale as prescribed for this surgery.

2. In case of surgery performed not listed in the table, compensation will be paid in an amount equivalent to the estimated cost for a surgery of similar severity.

3. In the event that more than one surgery is performed through the same incision, the company will only pay for the surgery with the highest compensation level.

4. In case more than one surgery is performed through different incisions in the same operation by the same surgeon, the company will pay based on the above mentioned instructions as follows:

<A> 100% of surgical expenses with the highest compensation level

<B> 50% of the fee for each additional surgery.

5. The terms of this policy only cover the type of surgery and not the consequences of the surgery.

6. For surgeries that must be performed multiple times, the next time the maximum payment will be 50% of the following surgery (excluding cases of bone fixation with nails).

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