Check claim decline and offer letters before they go out

Fields

• Handler's summary of the claim file
• Draft decline or settlement letter

Questions

1. What kind of claim letter is this draft? Choice

   Judge from what the letter does, not from its heading. When a letter pays for some of the claim and refuses the rest, it is a partial decline.

   • Full decline Refuses the whole claim and offers no payment, repair or replacement.
   • Partial decline Accepts part of the claim and refuses another part, or pays less than claimed for a reason other than the excess.
   • Settlement offer Accepts the claim and offers a repair, a replacement or a payment, with nothing refused.
   • Cash settlement Accepts the claim but offers cash instead of the repair or replacement the policy would otherwise provide.
   • Policy cancelled or avoided Refuses the claim because the policy is cancelled, or treated as never having existed, for example for a wrong answer given when it was taken out.
   • Request for information Asks the customer for documents or answers and gives no decision on the claim yet.
   • Decision unclear Reads as a decision, but a customer could not tell what will be paid and what is refused.

2. Does the letter name the policy term behind each part of the claim it refuses or reduces? Choice

   A term is named when the letter gives its section or heading together with its words or a fair summary of them. "Your policy does not cover this" names nothing. A refusal that rests on a term the letter has already named for another part, such as damage from the same cause, counts as named. The policy excess is not a refusal or a reduction.

   • Named for each Every refusal or reduction in the letter comes with the policy term it relies on.
   • Named for some At least one refusal or reduction names its term, and at least one does not.
   • None named The letter refuses or reduces something but names no policy term for it, or refers only to "your policy" or a general category.
   • Nothing refused The letter refuses and reduces nothing, apart from any excess, or gives no decision.

3. Does the letter give reasons for its decision that are specific to this claim? Yes / No

   Our standard: reasons say what happened, what we found, and why that means the term applies. Naming a term, or saying a report found the damage "is due to wear and tear", restates the label and is not a reason. Yes: The letter explains its decision with facts found on this claim, such as what the inspection showed on this roof or this pipe. No: The letter gives no reason, or only the label of a term or a general statement that would fit any claim of this kind.

4. When the letter refuses damage from a sudden event because of wear and tear or gradual deterioration, does it say what showed that? Choice

   Use the standard in the context on sudden events and gradual causes. A sudden event is one the customer puts the damage down to, such as a storm, a burst pipe or an impact. Poor maintenance counts as a gradual cause.

   • Explained The letter says what evidence showed that the gradual cause, and not the event, caused the damage.
   • Not explained The letter refuses the damage for a gradual cause but does not say what showed that the event did not cause it.
   • Not applicable The letter refuses nothing for wear and tear, gradual deterioration or poor maintenance.

5. Does the letter say what evidence was considered in reaching the decision? Yes / No

   Count a named report, inspection, set of photos, weather record, statement or estimate. "We have reviewed your claim" does not name evidence. Yes: The letter names at least one piece of evidence it considered. No: The letter names no evidence.

6. Do the facts the letter relies on agree with the claim summary? Yes / No

   Compare every fact the letter gives for its decision with the claim summary, including what the letter says a report or an inspection found. Judge agreement only; do not judge whether the decision is right. Yes: Every fact the letter relies on agrees with the claim summary, and where the summary holds evidence pointing the other way, the letter says why other evidence was preferred. No: The letter states a fact the summary contradicts, says a report found something the summary says it did not, or ignores evidence in the summary that points against the decision.

7. What does the letter say the insurer will pay, repair or replace? Choice

   Judge only what the letter says, not whether an amount is right. Do not check any sums.

   • Specific Says what will be paid, repaired or replaced, and names each deduction, such as the excess.
   • Deduction unexplained Says what will be paid, but takes off an amount it does not name or explain.
   • Vague Says a payment or repair will be made without saying what it covers or how much it is.
   • Nothing offered Offers no payment, repair or replacement.

8. Does the letter tell the customer they can send more evidence for the decision to be looked at again? Yes / No

   Yes: The letter says the customer can send more evidence or information, such as their own report, and that the decision will be reviewed. No: The letter does not offer to look at the decision again on new evidence, including when it only offers a complaint route.

9. Does the letter tell the customer how to complain about the decision? Yes / No

   Yes: The letter says the customer can complain and gives a way to do it, such as a phone number, an address or an online form. No: The letter gives no way to complain.

10. Does the letter tell the customer they may be able to refer a complaint to the ombudsman named in the context, with its website address? Yes / No

    Answer for the letter as written, whatever its type. Yes: The letter names the ombudsman in the context as the next step after a complaint and gives its website address. No: The ombudsman or its website address is missing, or a different body is named.

11. How easy is the letter for the customer to follow? Scale

    Judge the letter as a customer with no insurance knowledge would read it. Policy words quoted to name a term do not count against the letter when it also explains them.

    • Clear Short sentences, terms explained, no internal names or codes.
    • Some jargon Mostly clear, with a few unexplained insurance or legal terms, internal names or long passages.
    • Hard to follow Insurance, legal or internal wording throughout, or a structure the customer could not follow.

12. What should happen to this draft claim letter before it is sent? Choice

    Judge the draft against our letter standards as a whole. This suggests where the letter goes next; it is not a view on whether the claim should be paid.

    • Send as is The letter meets every standard and has no other problem worth stopping for.
    • Back to the handler to edit The decision and its reasons hold up against the file, but wording is missing or unclear, such as the complaint route, the ombudsman or the offer to look again.
    • Technical review A senior handler should look at the reasons: they are generic, do not fit the file, or refuse for a gradual cause without saying what showed it.

Lens columns

letter_type, letter_type_probability, clause_named, clause_named_probability, reasons_given, reasons_given_probability, gradual_cause_explained, gradual_cause_explained_probability, evidence_named, evidence_named_probability, consistent_with_file, consistent_with_file_probability, payment_terms, payment_terms_probability, new_evidence_invited, new_evidence_invited_probability, complaint_route, complaint_route_probability, referral_right, referral_right_probability, plain_language, plain_language_average, send_decision, send_decision_probability