When Is an Insurance Claim a Complex Claim?

Complex claim pic
Complex claim
Image: riskandinsurance.com

A resident of Wilkes-Barre, PA, Daniel Hohal oversees complex workers compensation claims in the New York and New Jersey jurisdictions on behalf of Berkshire Hathaway GUARD Insurance Companies. Daniel Hohal has served this leading insurance firm for more than a decade. Since 2015, Dan Hohal has held the title of complex claims supervisor.

Complex claims are a large factor in the cost of healthcare and health insurance. They require special attention from well-trained adjusters who are experts in their field and within their jurisdiction. An insurance claim may be considered complex if:

It is a very high cost claim. The larger a claim is, the higher the potential for abuse, error, or waste. Sending abnormally high-cost claims to a complex claims expert can help maintain appropriate payouts and reduce certain risks.

The claim does not match predictive modeling expectations. Computer modeling can predict expected treatments and the costs of those treatments with a great deal of accuracy. When a particular claim varies from what the predictive modeling suggests, it is likely complex enough to justify additional review.