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7 Common Claim Challenges

Aged Care businesses in Melbourne and throughout Victoria are no different to operators Australia-wide in that they are exposed to a wide range of risks that make reliable Aged Care Insurance essential, and the likelihood of claims high. For this reason, it is important to understand challenges that may arise when making claims so that, should it come down to it, this process runs as smoothly as possible and there is little business interruption.

Learn more about the claims process, potential challenges in the Aged Care sector and how to navigate these successfully to ensure efficient claim settlement and compensation.

The claims process

  1. Contact the Insurance Broker as soon as possible to notify them of the incident.
  2. With the assistance of the Broker liaise with specialist assessors and restoration firms to minimise the potential impact on staff and residents.
  3. Collate all supporting evidence and documentation in relation to the incident.
  4. The Assessor compiles a report detailing all particulars in relation to the incident for the Insurer’s consideration.
  5. An outcome is negotiated which aims to be fair and reasonable, and to return the affected party to their pre-loss potion. This could involve payment of trades or even compensation for the loss of income attributable to the claim.
  6. Claim payments follow.


The 7 Common Challenges

1. Delays in claim notification and therefore settlement

For claims that are lodged after the damage has been rectified with minimal supporting documentation, these can be difficult to position with the insurer. Early notification is always prudent, and enables the Brokers to provide clear guidance. This is important even if just to draw attention to a potential issue.

2. Claims for incidents that are not “sudden and unforeseen”

Claims involving, for instance, items that have been subject to wear and tear and gradual deterioration, can be difficult to substantiate as Insurance is not intended to be a maintenance policy.

Advising the Broker and discussing the likely response under the Insurance Policy could be the most efficient means of addressing these matters. It may be that whilst certain aspects of the claim are not covered there may be other components that are.

3. Disputes surrounding claim amounts

If there are disagreements regarding the amount that will be offered as compensation, this may prolong the process of settlement. It is important all parties understand the expectations and true extent of the incident.

4. Complications with incident documentation

If documentation is not adequate, this complicates proof of liability and leads to a lack of clarity on the incident that affects the process.

5. Difficulty understanding policy terms

Lack of communication, or intricate policies explained in unfamiliar language, may lead to misunderstanding that affects the claim process. To avoid this, it is important to discuss policy terms with the Broker and clarify contentious points with the Insurer. It may be that certain policy provisions are subject to interpretation.

6. Poor risk management

Inadequate risk management practices may lead to frequent incidents, and therefore a higher frequency of claims. A higher number of claims causes higher premiums, as well as more difficulty navigating claims. This can also result in a risk becoming undesirable to new Insurers, which is problematic and will further increase premiums for Aged Care facilities.

7. Limited resources

Low staffing or internal resources may affect the claims process. This impacts reporting, documentation and negotiation as people with limited availability or understanding of claims may be left to handle these. In the aged care industry, this may also lead to a higher frequency of incidents due to a lower quality of care, as Lockton explains.

Successfully navigating challenges

In order to ensure the claims process runs smoothly and receive compensation in a timely manner, you can work to avoid common claim challenges. You may do this by:

  • Maintaining detailed incident reports and documentation to provide clear evidence and a holistic view of the incident to avoid disputes.
  • Engaging with providers as soon as possible to receive guidance and prepare the Broker for claim management.
  • Maintaining good risk management to reduce claim frequency.
  • Ensuring good relationships with Brokers so as to support each other in the process.

Reliable Aged Care Insurance in Melbourne and throughout Australia with Atlantic

Atlantic Insurance has offered reliable business insurance to Aged Care facilities since 1995. Our experienced, dedicated team ensures claims are handled efficiently, as well as ensuring you remain informed of any changes to legislation that may impact your coverage.

At Atlantic, we work to educate and advise so that you receive comprehensive insurance cover tailored to the specific requirements of your facility. Contact us to receive comprehensive Aged Care Insurance in Melbourne and Australia-wide.

Any information contained on this page of the website is general advice only and has been prepared without taking into account your objectives, financial situation or needs. Your should consider these, having regard to the appropriateness of this advice and the relevant Product Disclosure Statement (‘PDS’), Target Market Determination (‘TMD’) and Financial Services Guide (‘FSG’), which will be provided following any formal recommendation to you.

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