Tag Archives: Audit

The Importance Of The Pre Bind Claims Review In The Reinsurance Context

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Don’t leave the gate open. Let a pre-bind claims review ensure you are secure in that new risk

I recently had a conversation with one of our Lanzko Associates, Nigel Shepherd, about the importance of conducting a pre-bind review in the reinsurance context. He was relaying a story from his past about how a POST bind review showed a significant exposures, which had not been reflected in the line of business profile contained in the client’s submission. This unknown exposure was largely responsible for that reinsurer going into run-off.  It was a preventable event had the review taken place prior to binding.

A lot can be uncovered when reviewing claims in advance of binding a new risk

Pre-bind reviews can greatly improve the information normally found on a submission. Claim numbers are just numbers when there is no context of information to understand the operation that supported them.

A good pre-bind review can help to:

  • Uncover unknown issues about department staffing and operational deficiencies that could affect future reserves and loss payouts.
  • Understand the reporting and reserve controls to see if there are impediments to setting appropriate reserves.
  • Determine the nature of the reserve philosophy and how it is employed to learn if reserves reflected are likely to be increased or decreased significantly prior to payments.
  • Ensure a claims system can handle reporting needs of the reinsurer as well to see if it is designed to improve efficiencies and help, not hinder, the managing of claims.
  • Learn how effective cost cutting initiatives, such as anti-fraud programs, litigation management and subrogation, truly are.

Why take the risk?

I asked attorney, and fellow blogger, Phil Loree of the Reinsurance and Arbitration Law Forum, as to his views on pre-bind reviews and he said:

“A pre-binding audit is a dispute-prevention technique.  While reinsurers can in appropriate cases obtain rescission when a cedent fails to disclose facts material to the risk, why buy a costly lawsuit or arbitration proceeding that could have been avoided by a modest, upfront investment of time and money?”

So why do companies take the risk of not conducting pre-bind reviews? There are always a multitude of factors that can come into play and mostly center around cost. Reinsurance companies with no in-house claims departments sometimes don’t have the staff to handle these types of reviews. Even the ones that do are usually faced with departments with claims to manage, and accounts to audit, with pre-bind reviews running low on the priority list.

Regardless of the reason, the failing to conduct a pre-bind review can be a risky venture.

For a healthy dose of good business judgment, an ounce of prevention goes a long way.

Absence of procedures to notify reinsurance is a basis for bad faith

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Recently I was discussing bad faith and notice procedures with attorney Phil Loree Jr., an expert on reinsurance and arbitration issues and author of the the Loree Reinsurance and Arbitration Forum blog.  I thought this was a timely conversation as it reinforced the concepts regarding procedures and the potential risks when they are not in place. As with my recent post regarding the breakdown of procedures in a insurance agent’s office, the cost of failing to have proper policies in place was at issue (see my article Failing to document files can be costly).

Phil reminded me of the seminal case of  Unigard Security Insurance Company Inc v. North River Insurance Company 4 F3d 1049 (1993). The case established the rule that an insurance company can be held to have committed bad faith for lack of notice to a reinsurer if there was a showing of recklessness or gross negligence. The court found that the failure to implement a policy to notify reinsurers could be an example of a willful disregard of the risk to the reinsurer and would be considered gross negligence.

Unigard and the proposition of bad faith

A high level of good faith is owed to reinsurers

The Court in Unigard first began by defining the level of good faith owed by an insurer to their reinsurer:

“…the duty of good faith requires the ceding insurer to place the reinsurer ” ‘in the same [situation] as himself [and] to give to him the same means and opportunity of judging … the value of the risks.’ ” [citation omitted] …Nevertheless, because information concerning the underlying risk lies virtually in the exclusive possession of the ceding insurer, a very high level of good faith–whether or not designated “utmost”–is required to ensure prompt and full disclosure of material information without causing reinsurers to engage in duplicative monitoring. [citation omitted]. The question, then, is what good faith requires of a ceding insurer in the notice context.”

The establishment of the bad faith standard

The court continued to establish a standard for bad faith that is differentiated from simple negligence:

“… we do not think simple negligence in not disclosing a material fact constitutes bad faith. … Virtually every material non-disclosure will be the result of at least negligence, and, if bad faith and negligence are equated, no showing of prejudice would ever be required.

We thus think that the proper minimum standard for bad faith should be gross negligence or recklessness. If a ceding insurer deliberately deceives a reinsurer, that deception is of course bad faith.”

Lack of procedures alone can be deemed reckless

With the standard established as gross negligence or recklessness, the court discussed how the failure of implementing proper notification procedures was essentially a reckless act:

“However, if a ceding insurer has implemented routine practices and controls to ensure notification to reinsurers but inadvertence causes a lapse, the insurer has not acted in bad faith. But if a ceding insurer does not implement such practices and controls, then it has willfully disregarded the risk to reinsurers and is guilty of gross negligence. A reinsurer, dependent on its ceding insurer for information, should be able to expect at least this level of protection, and, if a ceding insurer fails to provide it, the reinsurer’s late loss notice defense should succeed.”

To have procedures or not, that is the question

There is an ongoing debate in the insurance industry about maintaining claim policy manuals as a potential risk in a bad faith action. The view is that if you have specific written procedures, and your claims staff does not follow them, then that could be used against them in a bad faith action. Here a court specifically states that failing to have procedures could be considered bad faith in the reinsurance notice situation. Recently, Claims Magazine discussed the very topic in an article by Kevin Quinley, Putting Procedures In Writing (Claims Magazine, 1/5/2010).  I agree with the general proposition from the article:

In terms of bad-faith worries and claim manuals, it is often better to explain one miscue than to tell a judge or jury that the insurer has nothing in writing for claim personnel to use as their guide, and that there are no minimum performance requirements.

Whether in the Unigard example above, or in the recent award against the agent I previously commented on, failing to have procedures or follow them can have a costly outcome. Claim handlers need some kind of guidelines to understand expectations, and to establish a baseline to measure performance. When handlers are trained on good practices, and are measured on those practices for compliance through and internal review or audit program, risks are diminished.

Focusing on good claims practices will not only lower exposure to bad faith, but will help reduce leakage, lower expenses and improve customer service.

Failing to properly document files can be costly – It cost one insurance agency $5.83 Million

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Put procedures back in place before the pieces come apart

Whether it’s a claim file, an underwriting file, or in this case, an agent’s file, the lesson is the same. Proper documentation is going be more persuasive evidence that something took place. A recent example of that has just been reported in National Underwriter. A California insurance agent failed to document the absence of Workers’ Compensation coverage pursuant to state law. The agency had guidelines in place to ensure files were properly documented, but court papers indicated that they failed to follow their own procedures. This small mistake cost this agency over $5 million. Yet another example of what happens when the file fails to speak for itself.

Sometimes cliches are the best way to state the obvious: If it wasn’t in writing, it didn’t exist.

A few additional lessons learned:

  • Evaluate procedures regularly, and make sure they are effective
  • Audit and review your files for procedural compliance
  • Files should tell a story that documents what transpired
  • Even good procedures are useless if you fail to follow them