Insurance

Insurance conversations are enormous in volume, heavily repetitive and regulated. How a claim conversation goes affects whether the customer renews, and often what the claim costs.

Telonic agents are built for insurance: they know what a policy, an excess, an exclusion and a first notice of loss are, and the rules attached to each. The agent handles the conversation and the process around a claim. The claims decision stays with your team, always.

How the lines differ

The lines behave differently, and the agent is built for each.

In health, "am I covered?" is really three questions: the plan tier, the provider network, and whether the treatment needs pre-approval (the agreement, before treatment, that a procedure is covered). Once your plan, network and pre-approval data are connected during implementation, the agent answers all three from the member's own plan.

Who runs the health conversation

Much of the day-to-day health conversation is run by a third-party administrator (TPA): a company an insurer appoints to manage member services, provider networks, pre-approvals and claims on its behalf. A member asking about a pre-approval may be dealing with the TPA rather than the insurer.

Telonic works with whichever organisation runs the conversation, and connects to the systems that hold the member's plan, network and pre-approval status. Where both are involved, bring the TPA in at the start, because the systems and the process sit with them.

The conversations the agent takes

Each workflow below is configured during implementation for your products, with your claim-type questions, documents and approved policy wording.

First notice of loss, at any hour

First notice of loss is the first report of a claim. The agent checks the policyholder is safe, confirms who they are and finds the policy. It then asks the questions your process requires for that type of claim, in the order it requires, and asks for the right documents the first time. The claim is logged in your claims system in the structure it needs, and the policyholder receives a reference and a list of what happens next, in writing.

Claim status and documents

"Where has my claim got to?" is the question claims teams hear most. The agent answers it from your claims system, and sends an update when the claim moves to a new stage. Claims often stall on a document nobody chased rather than on the decision. The agent requests what is missing, receives documents and photos on WhatsApp, email or the web, and attaches them to the claim.

Coverage questions, from approved wording

The agent explains what a policy covers, the excess (the part of a claim the policyholder pays), the exclusions and how to make changes, from the policyholder's own policy and the wording you approve. It cannot describe cover that is not in the policy, because the facts come from your systems and documents rather than from the model. When a policyholder asks why something is not covered, the agent explains what the wording says, records the question and offers a person.

Renewals and brokers

The agent sends renewal reminders, answers routine renewal questions and explains a price change using the material you approve. It also serves brokers and intermediaries, who bring a substantial share of business in the region: policy checks, document requests and status queries, at the same standard as your direct customers.

The claims decision stays with your team

Some questions sit close to the decision. In a motor claim, which insurer the customer should be dealing with depends on who the police report says was at fault, and customers often call again to find out. The agent explains the process your approved material describes. It never gives a view on fault.

Vulnerable customers and difficult moments

A policyholder reporting a claim is often stressed. You set the signals that show a policyholder may be vulnerable or distressed, such as a mention of injury, bereavement or not coping, and the agent routes those conversations to a person with the full conversation handed over. This routing is configured during implementation. The agent also notices frustration as a conversation goes on, and hands over before it goes wrong.

Bring compliance in early

In insurance, compliance owns what the agent is allowed to say, so we walk your compliance team through the controls before go-live, not at contract. The agent answers coverage questions only from wording your compliance team approves.

Answers that must be word for word, such as a regulated explanation, can be set as exact scripted responses. Required disclosures can be set to be said at defined points in the conversation. Both are configured during implementation.

Every answer is on record, with the source it came from. When a policyholder complains to the regulator, you can show exactly what they were told, and when. Compliance flagging, configured during implementation, checks conversations against rules you set and flags them for review. See Compliance flagging and Audit trail and decision records.

What the agent takes, what it prepares, and what stays with your team

See Decision boundaries.

The systems the agent works in

Each connection has its own permissions, set with your IT team. An insurer typically grants read access to policies and claims, and permission to create a claim and attach documents, but no permission to change a claim's status or reserve (the amount set aside to pay a claim). See Permissions.

How a first deployment starts

Start with one queue: motor claim status and document chasing, or network and coverage questions for one health product. The agent runs alongside your team, and routing can send conversations back to your team at any time.

Before go-live, you and Telonic agree what will be measured, so your first review looks at your own conversations. For insurance, that is usually days to resolve, repeat contact, how often documents and first notices arrive complete the first time, and how often the conversation goes to a person.

Bring compliance in first, because every customer-facing answer at an insurer answers to the regulator. Then whoever runs your policy and claims systems, the TPA if health is in scope, and your legal team for call recording consent.

In practice

Wadi Assurance starts with motor claim status and document chasing.

1. Its claims system is connected with read access to claims and permission to attach documents. Its compliance team approves the wording for status updates and the document list for each claim type.
2. Tariq's claim MTR-31877 is waiting for a police report and a repair estimate. The agent sends him an approved WhatsApp message listing both.
3. Tariq replies with photos of both documents. The agent reads them, attaches them to the claim, and tells him the claim has moved to assessment.
4. Two days later, he calls to ask how much he will be paid. The agent gives him the claim's status, explains that the claims team sets the settlement amount, and books a call from his handler.
5. At the monthly review, the claims team sees how many files had complete documents first time, how often policyholders called back, and which conversations went to a person.

What your team controls

• Which products, lines and processes the agent covers first.
• The policy wording and guidance it answers from.
• Answers that must be word for word, and the disclosures it must give.
• The signals that route a vulnerable or distressed policyholder to a person.
• Which actions it can take in your policy and claims systems.

See The controls your team holds.

Related

• Decision boundariesGovernance and control
• Industry modelsAgents
• Insurance integrationsIntegrations
• Compliance flaggingQuality and analytics
• Audit trail and decision recordsGovernance and control

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