Written by Wang Shuran
Edited by Chen Jiying
Because the insured suffers from a malignant tumor and has not been diagnosed by histopathological examination, so it is not a major illness as stipulated in the clause, the compensation will be 0 yuan".
In December last year, when Enron applied for a claim for her mother with advanced lung cancer, she received such a notice of rejection.
Enron's first reaction was "don't understand, don't accept".
At this time, Enron, who was relatively lacking in insurance and medical knowledge, had been exhausted by his mother's serious illness, and had neither the energy nor the mental strength to study professional knowledge and fight for his own rights and interests.
In the end, with the help of the mediator of Ant People, she got a total of more than 8,100 yuan in compensation.
However, not all denials can be reversed through mediation. In some cases, the insurance company has good and reasonable reasons for the denial.
For example, Zhang Yu once purchased a million medical insurance for his daughter. In February last year, my daughter was unfortunately diagnosed with congenital cerebrovascular malformation. However, before purchasing the insurance, Zhang Yu did not notice the clause that "congenital diseases are within the scope of insurance liability exemption", so he could not accept the result of the rejection of compensation at all.
In fact, it is reasonable for the insurance company to say no to the situation that does not meet the conditions for claims - "the compensation that should be paid, the refusal to refuse", only the scientific use of insurance**, in order to protect the reasonable rights and interests of all policyholders.
And this kind of human nature and rationality is the limit of pulling, and the final judicial remedy is often mediation or litigation.
According to Ant Insurance's data, in the process of compensation, the insurance company and the user can reach an agreement in most cases, and in the case of compensation where the user has doubts and asks for help, less than 1% will eventually go to mediation or litigation. In 2023, there will be 4.69 million health insurance claims on the Ant Insurance platform, and only a few hundred cases will eventually enter the mediation process.
However, the demands of a small number of insurance users should also be paid attention to, and the mediator is the "underpinning" of these 1% appeals.
"You're here to help me? Or is it for me? ”
The people's mediator who finally won more than 8,100 yuan in compensation for Enron was Cai Kailu, who was born in the 90s.
In 2023, the Zhejiang Provincial Banking and Insurance Commission will set up the "Ant Mediation Studio" in Ant Group, which can provide one-stop claims mediation services for users insured by Ant Insurance.
Cai Kailu was one of the first people's mediators. In the past six months, she has handled mediation cases ranging from as high as 500,000 yuan for critical illness to as low as 2$8 ** fee.
And no matter how high or low the target amount is, Cai Kailu will go all out. Because she also had a similar experience, "I have been drenched in the rain myself, and I always think about holding an umbrella for others".
In 2020, his father was hospitalized due to cerebral hemorrhage, and Cai Kailu stayed at the door of the ICU for 14 days and nights, running all corners of the hospital when making a claim, and it took half a month to get more than 50 pages of information before completing the compensation process.
However, it is precisely because most of the people facing "special groups" that mediation work is not easy. "We often deal with people with serious illnesses, who are physically and mentally fragile and sensitive. ”
In August last year, she met Qi Ya, a young mother in her 30s, who was already in the advanced stage of liver cancer, and the treatment had exhausted her family's savings, and there was no hope of survival.
Qi Ya, who began to think about the aftermath, wanted to fight for a total of 300,000 yuan in critical illness claims for her 8-month-old children and elderly parents, so as to spend the rest of their lives in peace.
During the initial communication, Cai Kailu wanted to try to make the other party understand the insurance terms first based on a neutral position, but Qi Ya, who was depressed and collapsed, was easy to "stress", and once misunderstood that Cai Kailu was a lobbyist for the insurance company, "Are you here to help me, or to help the insurance company give me **?!" ”
Mediation cannot only rely on passionate sensibility, professional knowledge and logical rationality are indispensable in communication with insurance companies.
The reason for Qi Ya's denial of compensation is almost the same as Enron - the doctor used other diagnosis and treatment methods to diagnose Qi Ya's advanced liver cancer, but did not do pathological examination, and the latter is the premise of the insurance company's claim.
If she wants to fight for Qi Ya's claim space, Cai Kailu must find more powerful evidence.
To this end, in more than half a month, Cai Kailu consulted more than 50 pages of Qi Ya's medical records, studied hundreds of medical indicators, and consulted a number of clinicians to ensure an accurate understanding of the clinical significance of each abnormal index.
Finally, Cai Kailu summarized three types of medical diagnosis basis: positive alpha-fetoprotein tumor marker test; The patient underwent a ** regimen of chemoradiotherapy; Liver function B-ultrasound, magnetic resonance, CT and other imaging examination results. Based on the evidence, the conclusion of the refusal of compensation was finally changed.
On the day when the claim payment of more than 300,000 yuan arrived, Qi Ya specially communicated with Cai Kailu. She didn't cry when she was diagnosed with lung cancer, but she couldn't hold back her emotions at that moment and couldn't help crying. She said to Cai Kailu, "In my short life, I will always remember you and thank you."
Every time she recalls this scene, Cai Kailu is deeply moved, "Maybe this is the meaning and value of my work."
It can be seen that with sufficient evidence, there is also a chance to "bridge" the gap between clinical medicine and the insurance industry.
However, why is it often difficult for users to obtain reasonable rights and interests on their own?
Cai Kailu believes that on the one hand, because the professional knowledge of clinical medicine and insurance industry is complex and obscure, and the cognitive threshold is high, it is often difficult for users to have a clear and complete cognition, and then provide reasonable evidence.
On the other hand, it has to be admitted that users expect 100% full compensation, and the operation system of insurance companies is extremely professional and rigorous, so there will inevitably be deviations in positions and differences in interests.
The dilemma of neutrality
Empathizing with users does not mean blindly "favoring" users.
The foundation of the role of the people's mediator is neutrality, so as to ensure impartiality, to gain the trust of both users and insurance companies, and to become a bridge of communication between the two parties to the mediation.
For those situations where the claim should not be settled, the mediator should do itThe first is to know the reasonLet users form a reasonable understanding to avoid encountering the same dilemma again in the future insurance scenario.
Secondly, we must also know it with affectionLet users open their hearts and relieve their unresolved dissatisfaction.
Cai Kailu once met a sixty-year-old man who complained angrily to the insurance company for refusing to pay because he didn't know that the insurance claim was set up with a deductible of 10,000 yuan.
During the communication, the old man was emotional many times, and even threatened to go to the China Banking and Insurance Regulatory Commission to complain about the insurance company's fraud.
In the face of such a tricky case, Cai Kailu did not coldly cut into the terms at the beginning, first recognized his sense of risk protection, and also understood his anger at not getting a claim.
People's mediator Cai Kailu is working.
After some reassurance, the furious old man calmed down, and even praised Cai Kailu for being "very empathetic", and was willing to check the insurance terms, and finally recognized the concept that "the insurance company sets the deductible to reduce the cost of claims and operational risks".
After the mediation, the old man also said that in the future, he will take the initiative to promote the insurance claim mechanism, and also intends to recommend this insurance product to relatives and friends, "dare to refuse compensation for unreasonable claims, so that the product is safe."
However, neutrality can sometimes mean a dilemma.
In the face of those users who are in a difficult situation but do not meet the conditions for claims, the mediator will also be torn apart by human nature and reason - while sincerely wanting to help the user, on the other hand, it is the "closed door" of the insurance company.
Cai Kailu once met an insurance user in his 30s. In order to treat her father's liver cancer, she sold her real estate, spent more than 500,000 yuan before and after, and once received a compensation of 350,000 yuan, and invested all of it.
Later, she sent her father to a special needs specialist outpatient clinic that was not covered by the insurance claim, and the cost of the examination alone was as high as more than 20,000 yuan.
After the above-mentioned special medical expenses were denied, she had to cash out her credit card to maintain her father's **. However, the hard rules cannot be broken, so after mediation, the user still has not been compensated.
Cai Kailu encounters four or five such situations every month. She usually reminds the other party that if you want to pay a high amount of medical treatment in the future, it is best to communicate with the insurance company in advance to clarify the conditions of the claim and minimize the risk of denial.
Of course, Cai Kailu understands that the denial of compensation is reasonable and compliant, but she will still be troubled by the feeling of helplessness that she empathizes.
See the meaning beyond
In mediation, not only the result is important, but also the efficiency is the key.
Ant Mediation Studio has shortened the 13 steps of traditional mediation to 5 to 5, based on the platform model, you can generate mediation materials with one click, sign online, use seals online, and view online, and the whole process can be viewed and traced.
According to data from Ant Mediation Studio, hundreds of insurance claims were mediated last year, and the success rate of mediation (the insurance company and the user reached an agreement on the rejection and settlement of claims) was as high as 97%.
Moreover, more than 80% of mediation cases can be concluded within 5 working days. In contrast, the completion cycle of offline mediation usually lasts for weeks or even months.
In response to common problems, Cai Kailu and the other five mediators will summarize a unified mediation idea, and at the same time, they will also benchmark with insurance companies to improve and optimize the process.
For example, in response to the mediation case of "the user did not use medical insurance reimbursement first, and the insurance company can only pay 60%", Cai Kailu and her colleagues classified it, and benchmarked the solution with the insurance company for different situations such as "unable to use medical insurance, forgetting to use medical insurance, and using drugs outside medical insurance", including what information needs to be proved, whether there is room for mediation, etc.
After the process is streamlined and the standards are aligned, the compensation mediation of similar cases, which used to take 7 to 10 days, can now be completed in three days.
At present, Cai Kailu and his team are also trying to go to the forefront, promote insurance companies to clarify vague clauses, and promote insurance education front-end. According to the data, 95% of the compensation cases in which Ant Insurance users have doubts and ask for help are due to the user's lack of insurance knowledge.
Today, a number of insurance companies have gathered in Ant Insurance's "Bangbangshuo" community, and have launched the popularization of insurance claims and the optimization of practical rules for the topics that users have the most debates and doubts, which has triggered more than 17 million users' browsing and discussion.
In this sense, the Ant People's Mediator at the end has actually indirectly promoted the benign involution of the insurance industry. It is not only the users whose rights and interests are protected that benefit from it, but also the insurance industry that is trusted by more users.
The mediation mechanism builds a buffer zone between the user and the insurance company, clarifies the clear boundary between the claim and the rejection of the claim to the user, avoids the intensification of the conflict between the two parties, and tries its best to protect the rights and interests of the user.
The insurance industry needs more "Cai Kailu" to join in. In those accidents and sorrows related to the birth and old age, the kindness and rationality of "Cai Kailu" are both valuable and necessary. (An Ran, Qi Ya, and Zhang Yu are pseudonyms in the article).