Riskfin - Financial and Management Services

Groups Cover - Employee Benefits - Policies - Medical Aid - Funeral Policies - Insuarance

Claims Process

INTRODUCTION:

Riskfin provides funeral; Beef; and Tombstone benefits aimed at Funeral Group Schemes and Single Policyholders. The features of the benefit are underwritten by Safrican; and the premiums payable have been agreed. As the appointed Administrator; Riskfin will provide a full range of comprehensive administrative services except for the payment of claims. Claims are paid by Safrican

For Funeral Group Schemes; the funeral benefit cover relates to the main member; spouse; children and extended family members.

For single policy cover; the benefit relates just to the main member.

For Beef and Tombstone; the benefit cover relates to the main member; spouse; children. There are 3 options Member and Spouse < 65; Family including kids < 65 and Member and Spouse starting age 65 – 84. The maximum benefit cover is R7 000.

The Claims process from the time of submitting the claim to payment; should take approximately 48 hours.

Claims should be submitted within 6 months after death.

SUBMISSION:

A Client or Funeral Parlour can submit death claim documents either via fax; email or hand delivery to the Claims Administrator at the Riskfin Office.Claims will be processed by the Claims Administrator on the Riskfin Digital systems.An SMS can be generated from the system to notify the Claimants or Funeral Parlours of outstanding claim documents.

Processing of Claims:

Claim Assessment : Funeral / Beef / Tombstone ClaimIn the event of a death the Claims Administrator must ensure the completeness and validity of the claim and claim documents before processing a claim:
Completeness of claim documents/ application;

  • A signed and completed Riskfin Claim Notification form for Funeral claims
  • For Beef and Tombstone claims a Livestock claim form
  • An original certified copy of the Death certificate not older than 6 months
  • Latest copy of the bank statement for IndividualsBank statement for funeral parlour; copy only required once at inception
  • Certified ID copy of the deceased and claimant
  • A copy of the Participation certificate
  • If the death was caused through an accident; a copy of the police report
  • A beneficiary nomination form if livestock is selected
  • Copy of marriage certificate if spouse passed away
  • A copy of the BI1663 (Compulsory for all claims)

It should be noted that before the claim is processed a Participation certificate is generated from the system based on the policy holder’s membership number. The participation certificate provides the following details of the claim:

  • The Group or Individual policy holders name;
  • Policy Number; Product Description i.e. the premiums and respective benefits covered for;
  • Inception date of the policy;
  • Terms and conditions of the policy;
  • Members assured for the cover; 
  • Relationship; 
  • Inception date; 
  • ID number; 
  • Benefit covered for and Premium;
  • Finally documents required to process the claim.

The next step is for the Claims Administrator to process the claim on the Riskfin system. The Claims Administrator can search for the policy via the policy holders ID number / membership or policy number. This would present the policy holders membership details on the policy.
The following information is verified from the membership data:

  • The Members Initials and Surname;
  • ID Number;
  • If the Account is active;
  • Inception date;
  • The product information i.e. the cover amount;

The Claims Administrator would also verify if the Account detail is up to date i.e. if all premiums have been paid monthly. If 1 month’s premium is outstanding this must be requested and paid before authorising the claim for payment.

Dependent on the deceased the Claims Administrator will select either the spouse; child or extended and click on Death Claim. If the claim was previously captured there should be an error message displaying that (There is already a claim for this ID).

Thereafter the Claims Administrator will process the following claim information on the system:

  • Claimant Details (1st Screen):
    • Claimants name and surname;
    • Relationship with deceased
  • Deceased Details (2nd Screen):
    • Deceased name and surname;
    • Deceased id;Claim Amount;
    • Date of Death;
    • Cause of Death i.e. natural or unnatural
  • Bank Detail (3rd Screen):
    • Banking details of the claimant; NB. That if the claimant is the funeral parlour there is a box which can be ticked to indicate that we use the Groups Bank details; however if the claimant is an individual capture the bank details as per the copy of the claimants bank statement.

Once the Claim has been processed and captured the Claims Administrator will click on Choose Filled form which would allow the claims Administrator to print either a death claim form or Livestock claim form. The Claim form is system generated and populated with the following information:

  • Claim type i.e. Funeral ; Tombstone; Beef
  • Scheme name
  • Policy Number
  • Claimants details and claim amount
  • Deceased details and
  • Payment details

The Claims Administrator would verify that all details on the claim form are correct before signing the form. The claim form; participation certificate and supporting documents used for processing the claim are scanned and emailed to the Safican claims department for authorization and payment. Once the claim has been authorised and released for payment; Safrican will issue the Riskfin claims administrator with a unique claim number and the date the claim was paid. This will later be followed by an electronic confirmation on a Safrican letterhead.

The claims administrator will then select the accept claim icon on the system and tick claim accepted; input the claim reference number received from Safrican in the Underwriter claim ref. no. field and select the type of claim either Funeral; Tombstone or Livestock. From the system the claims administrator would initiate a sms notification to the client / funeral parlour informing them of the claim number; benefit amount and the date the claim was paid.


BEEF POLICY:

The claim process for the beef policy follows the same process as funeral claims. The only differing factor is the completion of a signed livestock claim form; in which the claimant has to either select livestock or cash. If the claimant has selected livestock a beneficiary nomination form has to be completed. The beneficiary nomination form will include the policyholders name; ID number; policy number the deceased full name and ID number. Full name of the provider selected to provide the Livestock i.e. Multi Brokers. On the participation certificate the claims administrator must verify that the claimant is paying premiums for the beef cover. On the claim form if the claimant has selected cash verify that the name of the recipient is the Funeral Parlour; however if the claimant has selected the Beef claim the name of the recipient is Multi Brokers.


TOMBSTONE POLICY:

For tombstone policies the livestock claim form is being used. The claimant can opt for either cash or a tombstone. Once again the claims administrator must verify that additional premiums were paid for the tombstone cover. All claims are paid to the funeral parlour. The process follows the same route as that for funeral claims.


WAITING PERIOD:

Death from Natural Causes: No claims will be paid within 6 months of inception date of the policy for all funeral schemes except Safas group and Thuso’s funeral undertakers which has a 3 month waiting period.
Death from Accidental: In order for a claim to be honoured the 1st month’s premium must have been received.

AUTHORISATION OF CLAIMS:

Before the claim is authorised it is indexed; checked by Credit control; membership data is loaded and the claim is assessed.
Indexing of Claims:
Upon the receipt of the claim documents from Riskfin, the documents are scanned and indexed by the Scanning and Indexing Team.  The documents are scanned and indexed according to the scheme numbers.  The Scanning and Indexing Team is based within the Claims Department.  The documents are scanned onto MIP system which is also the administration system.  The system restrict the Administrator (Indexing) from continue with other cases before finalizing the current case.  When the case is created on Workflow, the administrator has the option of finalizing it and route the case to administrator or park the case pending the receipt of outstanding documents.


Credit Control & Membership:

Once the claim documents are scanned, the documents are forwarded via the workflow to the Credit Control to verify the following:

  • That the premiums are up to date i.e. 6 months premiums have been received before the month of death.

The claim is forwarded to the dedicated inboxes in the Credit Control department.  The Claims Department cannot verify the premiums on the member level because some of the member records are not updated with premiums or member records not yet created on the system.  When the Credit Control Department has verified the details, the claim is forwarded to the responsible Claims Administrator.  The Workflow on MIP will indicate the user at Credit Control who verified the details and the Credit Control user also captures notes on the workflow.  The claims administrator forwards the claim to the Membership Department to load the member on the system to enable the Claim Administrator to process the claim on the system.  The members are loaded onto the system to avoid duplicate claim payments in future. The Membership Department must also verify if the premium and benefit amount is accurate.


NB: 
All the communication between the Scanning Team, Credit Control, Membership Department and Claims Department mentioned above is made via notes captured on the Workflow system.


Claim Assessment:

Claims are assessed and registered (captured) by the Claims Administrators after all the required documents have been indexed and membership info. has been loaded.  Tasks are assigned randomly to the inboxes of Administrators with a unique workflow number.  When assessing a claim, the Administrator checks and verifies the following details:

  • Personal details of the deceased i.e. to verify that no previous claim has been paid to the deceased
  • Personal details of the claimant
  • Proof of banking details.
  • Banking details in the case of known funeral parlours is only required once and captured on the system.
  • Subsequent claims do not have to attach proof of banking details.
  • Applicable waiting periods. Waiting periods differ according to the scheme. Waiting period is stipulated on the system, Contract Summary.
  • Certified death certificate and legitimacy of the certificate.
  • Certified copies of ID document of the deceased and the claimant.  If the deceased is the principal member, only his/her ID is required.
  • Marriage certificate in case of a death of a spouse or other proof of relationship.
  • Scheme name and if the status of the scheme is In Force
  • Proof of payment of premiums such as payslip or bank deposit slips. This is to ensure that the member was actively participating in the scheme.
  • In case of a death of a child with different surname, proof is required that the deceased is related to the principal member.
  • Letter of Execution (Dept Justice) in case where the benefits are paid to a guardian.
  • Confirm on Home Affairs website the status of the deceased on the Home Affairs records.(http://www.dha.gov.za/enquiry/living/status/get_living.asp).

The following are mandatory fields on the system that have to be completed before the administrator can proceed with processing the claim:

  • Names and Surname of the deceased.
  • Cause of death i.e. natural or unnatural
  • Date of death.
  • ID Number of the deceased.
  • Banking details into which benefits are going to be paid.
  • Benefit type i.e. either Beef; tombstone or funeral
  • Claim amounts to be paid for the different benefits

Once the claim has been assessed it is forwarded to Master Authorisation for Authorization.


Pending Claims:

If there are any outstanding requirements, the task will be marked as “parked” on the system until all the requirements are submitted and only then will the claim be processed.  The pending claim is communicated to the Administrator telephonically and in writing to follow up on any outstanding requirements.


Claim Authorisation:

Team Leaders and Claims Manager authorise claims once they have been captured, processed and assessed by the Administrators. They will review the claims captured by checking the following:The scheme is In ForceThe benefit is accuratePersonal details of the deceased and claimant are correct.All required documents are submitted (completeness of documentation).Accuracy of banking details and method of payment.The waiting periodThe details captured on MIP correspond with the supporting documentation.That the rules of the scheme have been complied with.
Claims will not be authorised if Team Leader or Claims Manager is not satisfied with all the requirements.  The task will be routed back to the Administrator who processed it, with comments stipulating what needs attention.  Once Team Leader or Manager is satisfied with everything he/she will give an instruction to pay the claim, by clicking “pay claim” on system.  The claim is now authorised and the status will read as “completed” on the system.  The task is then routed to the Accounts department for payment.  NB: There is an interface between the MIP system and accounts system. Once the claim has been paid an automated Payment confirmation is generated and saved on MIP. A copy of the Payment confirmation is forwarded to Riskfin to update their records and to inform the client. 

PAYMENT OF DEATH CLAIMS:

Payment of Death Claims for Riskfin is done via EFT and not by Cheque

Prepare Payment requisition (EFT)

The payment requisition is electronically prepared.  The bookkeeper extracts the Claim Authorized report from the MIP Life system and exports it to NedBusiness system for payment.  The parameters for the system to extract the Claim Authorized report is the transaction date (date claim authorized) and claim with Pad/Pay status.  The transaction date ensures that claims are not paid twice.  After the Claim Authorized report has been exported to NedBusiness, the bookkeeper will then extract the report from the MIP system as Update Payment report (EFT file) and check the report for duplications and completeness. The Update Payment report is a Read-Only therefore no changes or additions can be made to the file.  The file is automatically saved on the F drive on the network.

The bookkeeper imports the file to the system (NedBusiness) for EFT payment.  The payments have to be released by two releasers (managers).

After the payment has been released, the bookkeeper does the following:

  • Reconciles the amount paid and the banking details into which payment was made.
  • Captures the EFT reference number on the Update Payment Report and automatically the system will generate the confirmation of payment.

REPUDIATION:

A claim maybe repudiated for the following reasons:

  • The policy was cancelled before the death occurred hence the deceased member was not covered;
  • The death of deceased was as a result of suicide which occurred within 2 years of the policy starting date;
  • Despite request; necessary claim documentation (proof of relationship) has not been provided after the end of 6 month period for the submission of valid claims;
  • The member died in the waiting period (usually 6 months);
  • The deceased was not covered in terms of the funeral policy.
  • Normally only the principal member and his / her immediate family are covered unless specific documentation is supplied;
  • The BI1663 is outstanding when submitting the claim;
  • When the deceased member was married; a marriage certificate is a requirement;
  • Letter providing customary and / or common law marriage from the Department of Home Affairs (not an Affidavit).
  • All the claim documents must be clearly certified by “A Commissioner of Oaths”.
  • Computerized death certificate is outstanding;
  • If the cause of death is unnatural; a police report or a doctor’s letter is required depending on the circumstances.

Repudiation letters are prepared by Safrican and forwarded to Riskfin so that they can submit this to either the Funeral Parlour or individual member notifying them of the reason relating to the claim being repudiated.

ACCOUNTING:

The accounts division prepares and maintains the Cashbook, Bank Reconciliations and postings to the general ledger.

The accounts department monthly reconciles the claims paid as per MIP system and claims paid as per bank statement.  The reconciliation is reviewed by the Accounts Manager.

The following are accounting entries relating to payment of claims.
Dr.Claim Expense (20110) Head Office
Cr.Bank (10230)

(claims paid)

ADMINISTRATION SYSTEM:

  • The Riskfin Digital system is used by Riskfin Claims Administrator to process claims.
  • MIP Life – used by Safrican Claims Department to process the claims
  • NedBusiness – banking system used by Accounts Department to pay benefits

(Revised 12/01/2011)

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