Case Management - The road to recovery

Eddie Caplin argues that making rehabilitation an integral part of the follow-up process when assessing injury claims can not only lead to a higher level of customer satisfaction but also bring the added benefit of sharply reduced payouts

Cast your mind back 20 years. Your car has been hit. As well as negotiating with your insurer, you needed to obtain three repair quotations, hassle with the selected repairer to get your car back and accept that it was probably no longer as good a car as when you bought it. At the end of the day, you were not particularly impressed with your insurer but accepted that their prime interest was settling your claim with as little involvement and outlay as possible.

Compare this with how things work today. At the other end of a phone, a friendly, helpful insurance person will arrange for your car to be collected, repaired (or replaced) promptly and efficiently, then returned in excellent condition complete with a warranty. As a policyholder you are impressed by the service and happy to pay your premiums.

Insurance policies offer a restitution route to a pre-claim state - this need not be a purely monetary solution.

Now consider the parallel conditions for the driver who was hurt in the collision. About nine injuries in 10 are whiplash cases. What the driver wants is for the pain to go away, life to return to normal and to be in a position to forget the accident and move on. Too often this can only be achieved through a drawn-out legal process and arguments about money, but with little relevant treatment.

Rehabilitation offers a way of 'repairing' the claimant. Response can be prompt and effective. The experience of insurers who have tried this approach has shown higher customer satisfaction levels along with sharply reduced payout overall (saving not just thousands but millions of pounds).

Rehabilitation needs to be considered as an integral part of the follow-up process on every injury claim (involving insurers, lawyers, claims managers and claimants themselves) to lead to a change in perception of how best to deliver resolution of the personal damages suffered.

The "we've always done it this way" attitude is ripe for change, and this fresh mindset may need revised policy wordings and action for some positive engagement with policyholders.

This logic does not just apply in the motor sector. For example, employers' liability insurers are currently suffering the burden of society's changing attitudes, seeing escalating claims levels allied to pressures to reduce premiums. At present, around 8% of claims are passed along the rehabilitation route; it is suspected that over 70% could benefit. Again, a shift in the perception of what insurance is for (by claimants, insurers and the litigation process) can open a way to help make employers' liability and other personal injury policies more viable.

Permanent health insurance (also known as income protection) and occupational health both offer scope for parallel re-thinking. Perhaps the most surprising recent results have surfaced from trials the Department of Work and Pensions has been running with a view to placing long-term claimants back in the workplace. Using vocational caseworkers who provide a combination of rehabilitation and specialised counselling, the trials have consistently shown that it is quite feasible to return over a third of claimants, who were believed to be outside the work pool, back into productive employment.

Significant gains

Through proactive use of case management services and by concentrating on returning claimants to work, a significant portion of PHI reserves could be reduced to a short-tail liability. For employers, there can be real gains in absence reduction and productivity.

In May, the Better Regulation Task Force's report Better Routes to Redress recommended more consideration of both mediation and rehabilitation at an early stage in dispute resolution, together with the introduction of a wider discussion on how rehabilitation can generally be introduced on a much wider basis. The ABI has responded positively to this report along with other recent initiatives, emphasising how such reform can ensure that costs are kept under control.

Post Magazine, too, has been a leader in encouraging this approach through its 'Rehabilitation First' campaign, which has been instrumental in providing a forum to link insurers, claims managers and government with practitioners.

Medicals Direct is pleased to have sponsored this initiative.

Case management provides an envelope for rehabilitation services, taking a wider, whole person viewpoint. By assessing an individual's needs case by case, vocational caseworkers can identify and co-ordinate those practitioners needed to enable a return to work. Though well-established in North America, Scandinavia and Australasia, case management is relatively new to the UK. With a different structure to our health services, the focus in this country has historically covered management of particularly serious and complex cases. There is, however, a huge pool of less complex cases that are largely ignored, yet which through early intervention could return the sick back to normal life in a timely manner.

At an early stage, an assessment is made of the type and cost of intervention called for and, importantly, the likely time for recovery. Swift action from the start and continuous monitoring ensure the best recovery for the individual. If this is coupled with reduced inconvenience caused by absence and reduced costs, you can see why case management is flourishing.

An example may help. An employee rings in to report he is off with back pain again. A caring employer will sympathise, suggest rest and hope to see them back to work soon. However, the case manager's route is to assess the individual, arrange appropriate remedial work - in this case probably a physiotherapist - and then to monitor the return to work. This active, rather than passive, stance results in a happier employee, reduction in sick pay, elimination of the cost of a temporary replacement and the waste of management time. More importantly, by adopting an early intervention policy employers can make significant inroads into the cost of sickness absence. Savings of more than 25% are quite achievable.

There have been concerns about the levels of professionalism in providing return to work programmes. There have been no recognised quality standards for case management practitioners, leaving lawyers, insurers and employers no way of knowing how qualified or experienced the person is that they are instructing to look after the needs of a disabled person.

Unique training

The consequences of getting the choice wrong are potentially disastrous.

To remedy this, Medicals Direct, for instance, has passed case managers through a unique training programme, which has recently been accredited by Middlesex University. This programme includes examination of the trainees, together with ongoing quality assurance that will ensure that all our case managers continue to be among the most knowledgeable in the UK. We also make sure that they are all medically qualified with appropriate experience in fields such as occupational therapy, nursing, physiotherapy and psychology.

One of the features of cases involving those with severe injuries is the need for a case manager to co-ordinate the provision of care services for the accident victim. In cases of catastrophic injury this typically involves maintaining a care and nursing regime, liaison with local and national agencies and dealing with the victim's family. In less severe cases, the task might only involve a couple of telephone calls a week to arrange transport or monitoring visits.

Case management covers a range of tailored solutions, ranging at its simplest from a few encouraging phone calls to managed rehabilitation using a range of appropriate practitioners.

Rapid evolution

While rehabilitation and the more holistic case management approach are relatively new to the UK, these services are evolving rapidly. As they are applied in ever higher volume, so experience in choosing the most effective solutions will continue to build. In parallel, the attitudes of the public should adapt, especially if coupled with educational media coverage, and encouraging incentives provided for proactive treatment.

One unknown factor is the level to which the NHS will be able to complement such services. It seems most likely that funds will be applied in other areas for some years to come.

Of course, not every injury or sickness claim can be resolved by rehabilitation.

There are going to be cases where this approach will fail despite seeming to be the right one. But there is the potential for dealing with a large proportion of these claims either through a straightforward treatment regime or a more tailored vocational approach.

For these cases, insurers and claims managers (and claimants themselves) can win all ways through adopting a more pro-active approach to injury and disability claims using rehabilitation and case management services:

- Fix the underlying problem - don't throw money at it to make it go away

- Happier policyholders, claimants or employees = enhancement of your image

- Save money = reduced payouts

- Shorter claims cycle = reduced reserves

- Lower costs = lower premiums = more market share.

- The Medicals Direct Group is a leading service provider in the insurance, claims and occupational health sectors. For the life assurance sector, the group's medical services divisions provide nurse-based and doctor-based screenings, collect medical records, arrange medico-legal reports and claims assessment medicals. These services are provided nationwide.

Underwriting Direct provides real-time online underwriting services.

The Rehabilitation and Case Management divisions provide services described in the article above for insurers, the medico-legal sector and employers.

Medicals Direct Medico-Legal is an independent provider of medical evidence to the legal and insurance sectors.

A wide range of occupational health services is also provided, ranging from pre-employment assessments to dealing with long-term sickness issues.

The group offers focused, professional services throughout the UK. The scale of Medicals Direct's operations, intensive use of IT and many years' experience add up to service delivery and cost containment at levels that no individual company can achieve.

The group can be contacted on 0845 108 0446 or [email protected]

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