The purpose of this document is to (1) provide an outline of the services which the ACIG Claims Division ("Claims") provides to the shareholder on an as-needed basis, and (2) clarify areas of responsibility between ACIG Claims Division and the shareholder. This document further functions as the operating guideline to support ACIG Claims Division's mission statement, which is to reduce the overall cost of risk for our Members by (1) effective loss and expense reduction, (2) education and (3) professional management of incurred claims. Specifically, the services to be provided by Claims are as follows:
ACIG Personnel Assigned
Vice President - Claims Manager -
Responsible for the operation of the claims division at ACIG.
Claims Consultant - -
The Claims Consultant is responsible for overall claims management on designated accounts with supervisory responsibility for the activity of the claims technical service representative on those accounts.
Claims Support Manager -
Supervises TCA's; handles claim data issues both internally and externally, manages the help desk for RiskMaster. This position also oversees the contractor database and coordinates training for RiskMaster, the contractor database and the ww2 private web page.
Senior Claim Representative -
Manages all AL and GL claims reported to ACIG. Coordinates claim process with contractor and claims consultant.
Technical Service Assistant(TCA)-
Responsible for day-to-day activity on and the processing of claims information and support for the claims consultant and senior claim representative.
- Filing of Claims
Original claim reports will be filed directly with the servicing carrier by the shareholder with copies to Claims. Claims is responsible for distributing the necessary carrier forms as well as the internal Claims transmittal forms to the shareholder. The transmittal forms are used to code claim locations to create the management reports from ACIG's Risk Management Information Systems Division.
- Claims Manual of Procedure
This manual will be furnished in quantities requested by the shareholder for distribution to all offices involved in the origination of claims.
Claims will be available to provide assistance and consultation on technical claims issues which are of concern to the shareholder.
- Individual Claim File Supervision
Selection of specific individual claim files for supervision by Claims is based on an ongoing analysis of the number and severity of all cases in the ACIG inventory. The current Incurred Amount Threshold by line is:
Workers Compensation $100,000
A duplicate file is maintained by the claims department on those claims exceeding the above cost estimate thresholds. Copies of all correspondence are received, periodic consultations with the servicing carrier are conducted and a diary system is maintained on action items needed.
- Claims Below the Individual File Threshold
Claims with an estimated cost less than the thresholds outlined in number five above are not individually tracked by Claims, except through the periodic claim review meetings held with the shareholder and the servicing carrier representatives. It is the responsibility of the shareholder's representative to maintain close contact with the servicing carrier for claims in this area, contacting Claims for periodic input as needed.
- SWAT Team Losses
Claims will respond immediately in the event of an accident with high potential damages. The Claims Consultant may be reached by 24-hour cell phone as outlined in the Claims Management Procedures Manual. Claims will work closely with the shareholder's task force on these cases in the area of timely evidence preservation, witness contact, attorney selection and the formulation of defense (or plaintiff) strategy.
- Periodic Claims Review Meetings
Depending on the volume of open case inventory and possible problems to be addressed, Claims will schedule face-to-face meetings with the servicing carrier claims office(s) servicing the shareholder's operating divisions. Where possible, telephone conference calls will be used to maximize the effectiveness of the Claims' coordinator.
PREPARATION OF AND FOLLOW THROUGH ON AN ACTION LIST is the main thrust of these meetings. Responsibility assignments for follow-up on the action list will be made to appropriate representatives attending these meetings.
To maximize the impact of these meetings, case reviews should be limited to significant claims involving workers compensation indemnity and/or liability cases. Routine cases should be handled directly between the shareholder and the servicing carrier office on an interim basis.
Claims will coordinate the date for these meetings with the shareholder and servicing carrier representatives. The cases to be reviewed will be jointly selected by Claims and the shareholder and the resulting list will be sent to the servicing carrier office at least 14 days in advance of the meeting.
First draft notes of the meeting minutes will be given to the shareholder's representative at the conclusion of the meeting. Within five working days thereafter, executive summary minutes of the meeting will be sent to the shareholder's representative and top management as well as the servicing carrier outlining the action list created in the claims meeting.
- Annual Retro Claim Review Meeting
Approximately four months after expiration of the policy, Claims will hold a meeting with the shareholder and Servicing Carrier representative to review all open cases destined for inclusion in the "unit stat" data filing by the servicing carrier to the experience rating bureau. These meetings will be held between September 15th and November 15th. This service is designed to increase the accuracy of the claims data underlying the experience rating modifier to be published for the following year.
- Audits of Servicing Carrier Claim Offices
Claims will periodically conduct an audit of key servicing carrier claim offices to analyze the quality of investigation, timely and accurate reserving, early claims disposition at competitive figures and overall compliance with the Claims service agreement.
Medical and vocational rehabilitation assignments will be the responsibility of the shareholder's representative which will work closely with Claims in this important area.
This important activity is the joint responsibility of the shareholder's representatives. Claims will help identify potential subrogation situations.
- Outside Defense Counsel
While the choice of law firms and competent associates therein is the ultimate responsibility of the shareholder, Claims will supervise and consult on that selection process at the request of the insured. A master list of approved law firms will be maintained by Claims.
- In-House Training for the Shareholder
At the shareholder's request, Claims will conduct on-site training of the shareholder's personnel in the claims processing and management function.
- Claims (Loss Control) Workshops
Claims, in conjunction with the ACIG Safety Division, will hold one workshop each year devoted to the furthering education of its Shareholder representatives. Direct responsibility for format and agenda of these workshops is rotated among the Shareholders with technical input and supervision by Claims and Safety Divisions.