Insurance claims are an important part of the insurance contract and an important part of the insurance company's performance of insurance responsibilities.
With the continuous development of the insurance industry, the scale of premiums has grown at the same time, the number of complaints has also risen, and various problems that infringe on consumer rights and interests have also surfaced.
What are the trends in insurance claims in recent years?
At the beginning of 2024, the reporter noticed that some insurance companies and intermediaries have released claims service data for 2023. Among them, the number of annual claims of Chinese Life was 22.13 million, a year-on-year increase of 15.5%, and the compensation amount was 59.9 billion yuan, a year-on-year increase of 16.3%, and the odds were 99.7%. The cumulative amount of compensation paid by Tencent's official insurance agency platform, Tencent WeInsurance's "Safe Compensation" service, exceeded 4.3 billion yuan, and the online reporting rate of the platform exceeded 98%.
On the basis of traditional claims, in recent years, there has been an obvious trend of intelligent insurance claims: first, the proportion of online claims has increased, second, the claim settlement time has been shortened with the blessing of big data, third, the intelligent claims for emergencies have increased significantly, and fourth, the Internet insurance claim settlement model has continued to innovate, and services such as quick claims have been popularized.
While optimizing claims services, some people in the industry pointed out that there are still pain points in insurance claims such as users, companies, industries and the external environment. For example, due to the strong professionalism of the claim clause and the lack of understanding of the public users, the insurance salesperson misleads, the claim work is not developed in place, and the insurance company delays the claim.
Zhou Kejun, Chairman of Tencent WeInsurance, said, "Only by obtaining compensation can insurance intuitively and profoundly build user trust. This will also form a win-win insurance value for all parties and create more space for the development of Internet insurance in the future. ”
Wei Li, director of the Department of Insurance at the School of Finance at Renmin University of Chinese and director of the Insurance Research Institute of China, said: "In the past, the industry already had a complete set of indicators for insurance companies' compliance operations, but lacked a set of objective and transparent indicators to judge the level of claims service from the perspective of consumers. A good claims service needs to have quantitative measurement indicators and directions. ”
Chinese Life 2023 claims case won 99.7%
Judging from the data of leading companies, the case loss ratio of insurance companies is not low.
Taking Chinese Life, which was the first to release the 2023 claims service data, as an example, it was disclosed that its annual number of claims in 2023 was 22.13 million, a year-on-year increase of 15.5%, and the odds were as high as 99.7%.
Based on the data of the past two years, the case loss ratio of large insurance companies and well-known small and medium-sized insurance companies is above 99%.
According to incomplete statistics, in the first half of 2023, Taikang pension will have odds of 99.9%, and insurance companies such as Chinese Life, Ping An Life, PICC Life Insurance, CCB Life, CITIC Prudential Life, Sino-US United Thai MetLife, Tongfang Global Life, and Teckwah Angu Life Insurance will all have odds of more than 99%.
In the relevant data in 2022, the odds of Xinhua Insurance claim settlement reached 99.77%, Chinese Life Insurance reached 99.65%, Fosun Prudential Life Insurance was 99.5%, and Ping An Life and China Merchants Cigna Life Insurance were both 99%.
In addition to the loss ratio, the reporter noticed that the compensation amount of Chinese Life in 2023 has also increased. Specifically, its claims in 2023 will be 59.9 billion yuan, a year-on-year increase of 16.3%, 88,000 policies will be exempted from insurance premiums, with a total of nearly 940 million yuan of insurance premiums, and the claim settlement time will be 0.38 days, and the overall compensation will increase by nearly 12% year-on-year.
This trend is also reflected in the industry. Among them, Ping An Life paid 21.6 billion yuan in the first half of 2023, a year-on-year increase of 7.5%, Sunshine Life paid 2.26 billion yuan, a year-on-year increase of 19.1%, and Taikang Online paid 2.1 billion yuan, a year-on-year increase of 18%.
Critical illness claims are trending younger
Industry insiders pointed out that in the process of life insurance claims, medical insurance and critical illness insurance are the most likely to cause claims disputes. "The first is million-dollar medical insurance, with high leverage, low investment, and high insurance costs, and the second is critical illness insurance, with a high amount of compensation. In addition, the above-mentioned types of insurance are prone to problems such as 'the agent fails to explain the obligation to explain the standard clauses', so there are many claims disputes. ”
According to the report on insurance consumer complaints in the first quarter of 2023 released by the State Administration of Financial Supervision and Administration, there were 2,692 complaints involving life insurance companies in the first quarter, accounting for 18.2%.
According to the critical illness insurance claims data of various companies in previous years, the number of medical insurance claims accounted for the highest proportion, but the amount of critical illness insurance claims accounted for the highest proportion. According to the 2023 semi-annual report of Ant Insurance Claims Service, the average claim amount of critical illness insurance is 78,908 yuan, the maximum single claim amount is 1.6 million yuan, the average claim amount of inpatient medical insurance is 9,941 yuan, and the average claim amount of outpatient insurance is 94 yuan.
According to the semi-annual report of Huize Insurance, critical illness insurance still accounts for the majority of the claim amount, accounting for 68.89% of the claim amount, while in terms of the number of claims, medical insurance and accident insurance account for a relatively high proportion of 58.48% and 37.40% respectively.
Industry insiders pointed out that the average insured amount of critical illness insurance is low, but the amount of compensation is increasing year by year, the insurance rate is increasing and younger, and malignant tumors have become the main reason for claims.
Chinese Life's 2023 claims data points out that with the enhancement of people's health awareness and the development of diagnosis and treatment methods, the critical illness detection rate of people aged 25-45 underwritten by the company has increased from 6.3 per 10,000 in 2013 to 12 per 10,000 in 2022, and the critical illness claim shows a younger trend. At the same time, with the continuous improvement of medical standards, the 5-year survival rate of critical illness customers continues to increase, and critical illness insurance is more used to maintain the quality of life after suffering from critical illness.
In this regard, Chinese Life has optimized the critical illness claim service, and its "one-day critical illness claim" has now covered malignant tumors and some cardiovascular and cerebrovascular diseases, which account for the highest proportion of critical illness claims, with 244,000 claims in 2023, with a compensation amount of nearly 11.2 billion yuan, and nearly 95% of the critical illness claims that meet the standards can be paid in one day.
Obvious intelligence More than 98% of Tencent's life insurance users choose to report online
Intelligence is one of the main directions of insurance claims service. With the completion of the digital transformation of traditional insurance institutions, the continuous optimization of Internet insurance in digital mode, and the comprehensive digitization of medical bills and medical records, it is becoming possible to fully online and automate Internet insurance claims.
According to the Report on the Digital Development of Insurance Claims Services in China, the amount of claims paid by mainland insurance companies has shown a steady upward trend year by year in recent years, and the claims service experience has also continued to be optimized, with the average digitization rate of insurance companies' claims settlement approaching 90%.
According to the "2023 Research Report on Innovative Services for Internet Insurance Claims", the scale of premium income of Internet insurance by 2030 will increase by nearly 6 times compared with 2022, or more than 2.85 trillion yuan, and the amount of claims sold and completed through Internet channels will be close to 1 trillion yuan.
With the continuous growth of the scale of Internet insurance users, the pain point of easy to buy insurance and difficult to settle claims has become an urgent problem for the Internet insurance industry. In this regard, a number of insurance companies and intermediaries have made efforts to provide intelligent claims services to strengthen their service capabilities while facilitating users.
Among them, in 2023, Tencent Wesure will upgrade its platform service system to create an "insurance helper" that runs through the entire life cycle of users from the three links before, during and after insurance. In the claim settlement process, the company innovates online claim settlement tools and improves the whole process of claim settlement, and its "peace of mind claim" has supported the online claim settlement capability of multiple types of insurance such as life insurance, car insurance, and property insurance, and users can achieve one-stop self-service claim settlement after submitting claim information in the mini program.
According to the report, more than 98% of life insurance users on the microinsurance platform choose to report through the microinsurance mini program, and more than 85% of auto insurance users use the auto insurance claim service to check the progress.
Similarly, in terms of intelligent claims, since 2023, Chinese Life has piloted a full-process non-manual claim settlement project, shortening the manual operation time by more than 90%, and the proportion of automatic claims in the pilot area is 5%-15%. In addition, Chinese Life launched the application of medical electronic invoice claims, with nearly 5.08 million electronic invoice claims in 2023, with a compensation amount of more than 5.3 billion yuan and a compensation time limit of 0.30 days; at the same time, the electronic invoice reminder reported 567,000 cases, with a compensation amount of more than 600 million yuan and a compensation time limit of 0.14 days.
In addition, the reporter noted that Chinese Shou also applied for a patent for "an insurance claim data processing method and device" in October 2023, with the publication number CN117314655A, to solve the problem of relatively low efficiency and processing quality of the data processing process of the existing service system technical facilities.
Actively respond to sudden natural disasters
In addition to the above trends, in the summer and autumn of 2023, the mainland will be hit by a number of typhoons, and their average intensity and extreme intensity will greatly exceed the average of previous years. Under the typhoon, the extremely heavy rainfall brought economic losses such as damaged bridges, flooding of rice fields, damage to fishery and breeding, and flooding of vehicles.
As of August 6, 2023, insurance institutions in 16 disaster-stricken areas, including Hebei, Beijing, and Heilongjiang, have received 189,100 insurance reports, with an estimated loss of 6.241 billion yuan. 50,600 cases have been compensated, with a compensation amount of 264 million yuan. Among the insurance reports received by insurance institutions in 16 disaster-stricken areas, including Hebei, Beijing and Heilongjiang, 116,200 cases were reported for auto insurance, accounting for 61% of the total number of reported cases, with an estimated loss amount of 1.878 billion yuan, 7,081 cases were reported for enterprise property insurance, with an estimated loss amount of 1.622 billion yuan, and 24,100 cases were reported for agricultural insurance, with an estimated loss amount of 2.065 billion yuan.
In the process of responding to natural disasters, the insurance industry actively settles claims, participates in rescue, and gives full play to the function of risk "shock absorber". For example, it will play the role of risk early warning, assist the government in risk prevention, actively carry out accident rescue and disaster relief, and open green claims channels. Establish a 24-hour on-duty system for claims adjusters to respond to consumers' reporting and investigation needs in real time, and appropriately simplify the requirements for claim settlement materials to speed up the progress of insurance settlement.
According to disclosure, Chinese Life will respond to 178 emergencies in 2023, including the 6.2-magnitude earthquake in Jishishan County, Linxia Prefecture, Gansu, the 5.5-magnitude earthquake in Pingyuan County, Dezhou City, Shandong, and the Jinyang flood in Liangshan, Sichuan.
There are still "three major pain points" in claims service
As mentioned above, at present, the mainland insurance claims service has made breakthroughs in the odds, payment amount, payment speed, convenience and other indicators, but in reality, the "China Insurance Claims Service Digital Development Report" pointed out that the insurance claims service still has the pain points of high user awareness threshold, complex claim process and general claim standards.
One is the user aspect. Due to the strong professionalism of the claim clause and the wide variety of claim materials, it is often difficult for the public to understand accurately, and the repeated submission of materials leads to a poor application experience, and there are not a few claims complaints.
The second is the insurance company. The claims service of some companies cannot keep up with the rapid development of the insurance industry, and the main reasons behind the difficulties in claim settlement include: misleading insurance salespeople, inadequate development of claim settlement, interest index driven, insurance companies delaying claims, and insurance companies reluctance to pay compensation.
The third is the industry and the external environment. At present, the main reasons for the difficulty of settling claims include: the relevant legal system needs to be more sound, the society is full of public opinion that "it is easy to apply for insurance and difficult to settle claims", and there is a lack of claim standards for different types of insurance on the user side.
In this regard, a lawyer pointed out to reporters that while insurance companies optimize their services, consumers can also focus on two types of content in insurance terms when purchasing insurance: one is "what to insure", and the other is "what not to insure".
Among them, "what to insure" involves a liability clause, and "what not to insure" involves a deductible clause. The above-mentioned lawyer said that consumers must be clear about the scope of liability of the insurance when purchasing medical insurance, and the insurance company will only fulfill its obligation to pay compensation if an insured accident occurs within the scope of insurance liability.
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