Scenario Summary
A human adjuster handles a claim involving an insured with special needs. Despite available resources and proper procedures, the adjuster responds with passive sympathy rather than actionable assistance, resulting in service failure.
Failure Description
An insured reports difficulty securing temporary housing under ALE benefits. The insured explains:
“My husband is in a wheelchair and the hotel says they don’t have ADA rooms available.”
The adjuster:
- Acknowledges the situation with a sympathetic remark
- Does not take action to resolve the issue
- Fails to utilize available vendor resources (housing provider)
- Does not escalate or follow through
Instead, the adjuster responds:
“Oh that’s sad. They need to have more rooms available.”
No further assistance is provided at that moment.
Regulatory & Compliance Concerns
- Failure to Provide Reasonable Assistance
Carriers are expected to assist insureds in accessing covered benefits, especially when additional needs exist. - Inadequate Claims Handling
Knowledge of available resources without action may constitute poor handling. - Exposure to Unfair Claims Practices
Failure to act when solutions are available can be viewed as unreasonable delay or neglect.
Root Cause Analysis
- Human emotional distraction (“bad day,” fatigue, stress)
- Lack of focus or engagement during call
- Training not reinforced in real time
- Overreliance on post-call audits rather than live support
Impact on Insured
- Immediate problem remains unresolved
- Increased frustration and stress
- Loss of confidence in carrier support
- Potential escalation or complaint
Corrective Actions / Best Practices
- Reinforce action-based empathy training
- Implement real-time support systems during calls
- Require adjusters to offer solutions, not just acknowledgment
- Monitor for missed intervention opportunities
ClaimSurance Insight
Empathy without action is not service.
A response that acknowledges hardship—but fails to resolve it—can be as damaging as no response at all.
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