Case Study

National Accident & Health Insurer

Operational & Underwriting Turnaround

Situation

  • Small, single product A&H carrier with rapid growth in challenging regulatory environment
  • Exponential growth outpaced service capability resulting in long claims processing delays and overwhelmed service organization
  • Poor compliance controls caused multiple state DOI investigation and fines
  • Slow claims processing masked deep fundamental Underwriting (UW) control, product design and pricing issues

SMA Services

Strategic Review

Product Review

Pricing Optimization

Technology Alignment

Business Transformation

Actions & Impact

  • Created new operating infrastructure that included enrollment and claims processing, agent licensing, customer service and financial reporting, strengthening internal controls, enabling scalability with added functionality, all with $0 SG&A increase
  • Performed in-depth underwriting and pricing analysis and created new UW manual and pricing with proper controls
  • Worked with actuaries to design customized reserve calculation to properly reflect emerging liabilities
  • Did in-depth study on product design and isolated problematic features that drove significant losses

Results

$17M+ Gross Margins

– 30% MLR

Avg. Claims TAT from 60 to 10 days