đź“„ Insurance Resolutions

Case-Based Resolutions

Case 1: Claim Not Reflecting on Portal

Scenario: A beverage company’s employee was injured during warehouse operations. The HR manager submitted a claim, but it’s not visible on the RMA portal.

Resolution Steps:

  1. Confirm submission date, claim reference number, and employee details.
  2. Log into the RMA Employer Portal and check under “Submitted Claims”.
  3. If missing, verify whether the claim was saved as a draft or failed due to attachment errors.
  4. Escalate to RMA Support with claim reference, employer code, and supporting medical reports.
  5. Advise the employer to re-upload missing medical documents.
  6. Confirm with RMA Claims Department that the claim is being processed.
  7. Provide employer with SLA timelines (e.g., acknowledgment within 48 hours).


Case 2: Policy Cover Clarification

Scenario: A brewery queries whether employees injured during delivery outside the plant premises are covered.

Resolution Steps:

  1. Review policy document and confirm occupational injury coverage applies both onsite and offsite during official duties.
  2. Share extracts from the RMA policy on offsite accidents.
  3. If ambiguity remains, escalate to RMA Legal & Compliance for written clarification.
  4. Advise employer to keep detailed incident reports, including witness statements, in case of disputes.


Case 3: Premium Contribution Discrepancy

Scenario: The finance department notices higher-than-expected RMA contributions for the quarter.

Resolution Steps:

  1. Retrieve contribution calculation based on total wages submitted.
  2. Cross-check payroll submissions vs. RMA premium invoice.
  3. Identify if overtime/contractor wages were included.
  4. If errors exist, advise employer to submit an amended wage declaration.
  5. Request RMA to reissue corrected premium invoice.
  6. Document process to avoid recurrence during quarterly submissions.


Case 4: Employee Not Reflected as a Member

Scenario: A newly onboarded distillery worker’s details do not appear in RMA records.

Resolution Steps:

  1. Check whether HR submitted the employee via the RMA Employer Onboarding Portal.
  2. Confirm employee ID, work permit (if applicable), and start date.
  3. If submission was missed, assist HR with bulk employee upload.
  4. Request RMA to validate member details and confirm coverage start date.
  5. Provide HR confirmation email/letter for audit compliance.


Case 5: Compliance Audit Request

Scenario: A beverage distributor receives a compliance notification from RMA requesting workplace health & safety policy evidence.

Resolution Steps:

  1. Collect internal OHS policies, accident logs, and training records.
  2. Upload documents to RMA compliance portal.
  3. Liaise with RMA audit team for completeness checks.
  4. Provide employer with an escalation channel if further clarification is needed.
  5. Recommend scheduling an annual compliance review to prevent future issues.


Case 6: Portal Login Issues

Scenario: The HR manager cannot access the RMA portal before a deadline for claim submission.

Resolution Steps:

  1. Confirm internet/browser version compatibility (Chrome/Edge recommended).
  2. Check password reset and account lockout policies.
  3. If system outage, escalate to RMA IT Helpdesk and obtain incident reference.
  4. Request deadline extension from RMA in case of prolonged downtime.
  5. Share alternative submission channels (email helpdesk or direct submission via RMA support team).

Case 7: Claim Submission Error on Portal

Scenario: A client reports that their claim submission fails with an error code after uploading supporting documents.

Resolution Steps:

  1. Replicate the issue on UAT with similar document formats.
  2. Verify file size and extension validation rules in the portal.
  3. Check system logs for API errors between claim portal and backend system.
  4. If document upload service is timing out, raise a ticket with infrastructure to increase file upload threshold.
  5. As a workaround, advise client to email the documents to the claims team while fix is deployed.
    Tag: System Error | Claims


Case 8: Incorrect Premium Deduction

Scenario: A corporate policyholder notices an incorrect premium amount deducted for their monthly contribution.

Resolution Steps:

  1. Review policy configuration in the admin system.
  2. Cross-check premium table against underwriting rules.
  3. If miscalculation stems from incorrect rate update, roll back to last approved version.
  4. Raise adjustment note and process refund or additional debit as required.
  5. Confirm with client after correction and document root cause for audit.
    Tag: Policy | Billing | Compliance


Case 9: Duplicate Policy Creation

Scenario: A client appears twice in the system with two different policy numbers.

Resolution Steps:

  1. Validate client identity (ID/passport number).
  2. Check whether second policy was created via manual onboarding or bulk upload.
  3. Merge duplicate records using master policy number, ensuring claims history is retained.
  4. Cancel duplicate policy with regulatory-compliant remarks.
  5. Update CRM to prevent future duplication using unique identifiers.
    Tag: Policy | Data Integrity


Case 10: Delayed Claim Payout

Scenario: A claimant complains that their approved benefit payout is delayed beyond SLA.

Resolution Steps:

  1. Track payment instruction in ERP/finance system.
  2. Check whether payment batch failed or was held due to compliance flag.
  3. If blocked due to missing tax documentation, notify claimant immediately.
  4. Escalate to finance for urgent release of funds if all documents are complete.
  5. Send formal apology with revised timeline to claimant.
    Tag: Claims | Payments | SLA


Case 11: Occupational Injury Not Linked to Employer Account

Scenario: An injured worker’s claim is not showing under the correct employer’s account.

Resolution Steps:

  1. Verify worker’s employment details from HR records.
  2. Cross-check employer registration number on the claim.
  3. If employer linkage was incorrectly mapped, correct in policy master and reassign claim.
  4. Ensure no duplication of claim against wrong employer.
  5. Notify both employer and claimant about resolution.
    Tag: Claims | Policy | Compliance


Case 12: System Downtime During Peak Filing Period

Scenario: Portal crashes when multiple corporates submit claims during month-end.

Resolution Steps:

  1. Check server load and application logs.
  2. Scale infrastructure temporarily (add more instances, load balancer).
  3. Inform clients of downtime via SMS/email blast.
  4. Enable offline submission option as backup.
  5. Raise permanent fix request with IT for load-testing and system scaling.
    Tag: System Error | Operations | Client Servicing


Case 13: Incorrect Benefit Calculation for Dependents

Scenario: A claimant’s dependent benefit payout was lower than expected.

Resolution Steps:

  1. Validate dependent eligibility against policy rules.
  2. Check calculation logic in claims system.
  3. If dependent’s age/relationship misclassified, correct record and reprocess claim.
  4. Issue revised benefit amount with audit trail.
  5. Document policy interpretation and share with claims team to prevent recurrence.
    Tag: Claims | Policy | Compliance