Damages compensation investigation in insurance companies: analysis of the suitability of treatments, their costs and documentation / "Perícias de ressarcimento de danos em companhias seguradoras : análise da adequação dos tratamentos propostos, dos custos dos tratamentos e da documentação"

AUTOR(ES)
DATA DE PUBLICAÇÃO

2005

RESUMO

This dissertation aims at analyzing the data on accident claims in personal injury policies from insurance companies and at proposing improvements on the treatment of injured people who hold this kind of product. The study describes information related to the insured profile (gender, age and occupation), to the trauma (such as the place and etiology of damage), the lesion and rehabilitation treatment characteristics, as well as whether proposed treatments were adequate for the fees charged and for the documentary evidence submitted. Errors identified in policies with insufficient documentation were also listed. The study encompassed 151 claims, 132 of which were Notification of Accidents (Initial Claims) and 19 were Notification about the Eligibility for Continuity of Care. As for the kinds of insurance, 124 related to School Accident Insurances, while 07, to Professional Leave, and only 01 related to Motor Vehicle Personal Injury Insurance. In those claims, 84 (63,64%) insured were male, whereas 48 (36,36%) were female; the main age group ranged from 6 to 10 years old, totalizing 42 cases (or 31,82%). Schools were the place where the greatest number of accidents (57 = 44,53%) occurred. In the etiology of damage, it was observed that 59 accidents (44,70%) occurred during locomotion movement, 34 cases (25,76%) in playing, 18 (13,64%) during the practice of sports and 16 (12,12%) at home. In the last three types, fall accidents occurred more frequently. As for the kind of lesion, the simple fracture crown prevailed in 94 cases, whereas in 21 accidents, it were hard and soft associated lesions. In the rehabilitation treatments, dentistry prevailed in 112 proceedings. As for the suitability of proposed treatments, out of 151 claims, 133 were adequate whereas 18 were not. As far as fees for professional services were concerned, 89 were considered satisfactory, while 55 were considered overcharged. The last 7 claims were related to Professional Leave, and so what is assessed is the time to recovery and not the treatment costs. In relation to documentary evidence, 74 claims submitted proper documents, while 77 did not. The latter main error was that initial and /or final radiographic documentation was not sent to the insurance companies.

ASSUNTO(S)

insurance policy for personal injury seguros de acidentes pessoais avaliação de honorários profissionais trauma epidemiology epidemiologia do trauma assessment of professional fees

ACESSO AO ARTIGO

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