Question handling
Coverage questions an assistant must not decide
Three different questions arrive wearing the same words. Whether you accept a particular insurer is a fact about your business. Whether a specific policy pays for a specific thing is a decision that belongs to the insurer and turns on wording nobody in the conversation has read. Confusing the two is how customers end up with a rejected claim and a screenshot.
What they are really asking
Will somebody else be paying for this, and if not, what am I actually liable for.
- do you take my insurance
- is this covered
- will my insurance pay for it
- do you bill the insurer directly
- how much is my excess
- do i need a referral for my insurance to cover it
- can you help me make a claim
- what do i do if my claim is rejected
- do you work with any insurers
- will you invoice my insurer or do i pay and claim back
The material that answers it
An assistant is only as good as the document behind it, and for this question the document usually exists but is written in the wrong shape. What each one has to contain to be answerable:
| Which insurers or schemes you work with | A plain list, kept current, with anything conditional marked as conditional. This is a fact about you, it does not depend on who is asking, and it is the question that decides whether somebody books at all. |
|---|---|
| How billing works for each arrangement | Whether you invoice the insurer directly, whether the customer pays and claims back, what has to be authorised in advance, and what documentation you provide. The difference between these two models matters enormously to somebody deciding whether they can afford to proceed. |
| What the insurer requires before you can proceed | Pre-authorisation codes, referral letters, membership numbers, claim reference numbers. Listing what to have ready turns a two week back and forth into one appointment. |
| The exact wording you use on invoices and reports | Insurers reimburse against specific service descriptions. An improvised description of what something is can leave a customer with a rejected claim, which then becomes your problem rather than the insurer's. Index the wording you actually issue. |
| Your claims route and how fast it moves | Who handles a claim, how it is started, what information is needed on the first contact, and the deadline if there is one. Somebody starting a claim is usually somebody who has already had a bad day. |
How to handle it
Split the acceptance question from the coverage question
Do you take my insurer is answerable and should be answered cleanly and immediately, because it is a property of your business that never changes case by case.
Will my policy pay for this is a different question with a different owner. It depends on the individual policy wording, the limits, the exclusions and any pre-existing conditions, none of which are in your documents and none of which the assistant can read.
State the process, in the order the customer will experience it
Check with the insurer, obtain any authorisation, bring the reference, we invoice them or you claim back. Written as a sequence it is genuinely helpful and it is almost never published as one.
The sequence is also what protects the customer. Most rejected claims start with a step skipped at the beginning, not with a decision at the end.
Refuse the adjudication in one clear sentence
Whether something is covered is decided by the insurer against the policy wording, and the assistant should say exactly that rather than hedging. A hedge reads as a soft yes, and a soft yes on a coverage question is what produces the complaint.
Pair the refusal with something useful in the same message: what to ask the insurer, and the reference or code they will want.
Keep advice out of it entirely
There is a distinction in many regulated markets between giving factual information about insurance and giving a personal recommendation about it, and the second is a regulated activity. Suggesting which cover somebody should buy, or whether a policy is any good, crosses a line you do not want your support widget standing on.
Keep the indexed material to what you accept, how you bill and what the insurer needs, and the distinction takes care of itself.
When it stops being an answer
Any live claim
A claim in progress, a claim rejected, a dispute about what was authorised. Claims run on deadlines and on documents, and they need a person who can look at the file. The assistant should collect the reference and hand over immediately rather than explaining the general process to somebody who is already inside a specific one.
Whether a particular treatment, repair or item will be paid for
Even where the answer looks obvious from your own experience, the assistant is answering to an anonymous visitor about a policy it cannot see. The correct behaviour is to give the process and the route, never a prediction about the outcome.
Anything about excess, limits or what the customer will owe
These come from the policy schedule, not from you. An assistant that estimates somebody's out of pocket cost has produced a number with no source, and it will be quoted back at the point when the real invoice arrives.
How this one goes wrong
The coverage answer that became a rejected claim
Somebody asks whether their insurance covers something, the assistant matches against a page describing an insurer you work with, and produces an answer that reads as confirmation. They proceed on that basis, skip the authorisation step, and the claim is refused.
The customer is now out of pocket for something they were told would be paid, by your business, in writing. Whether the wording technically committed you is beside the point; the relationship is finished and you will probably absorb the cost anyway. Cautious matching, a clear separation between acceptance and coverage in the material, and a refusal that names the insurer as the decision maker are what keep this from happening.
The same question, trade by trade
The pattern above holds everywhere. The wording, the escalation line and the material behind it do not, so there is a page per trade.
- For a dental clinicA capitation plan is not insurance, and neither decides what a claim pays. What to publish about plans, claim forms and authorisation.
- For a medical practiceThe insurer asks the practice for a report with the patient's consent. What can be said about consent, who pays and who decides.
- For a veterinary clinicDirect claims, deposits and paying on the day. What a vet practice can state without predicting what an insurer pays.
- For a physiotherapy clinicRegistration, authorisation codes and session limits. The insurance answer that decides whether a physio books.
- For a opticianOptical cover arrives as vouchers and entitlement rather than claims. What the assistant confirms and what it cannot.
- For a pharmacyExemption, private medical cover and travel insurance get asked in the same words, and only one of them touches a pharmacy counter.
- For a law firmProfessional indemnity cover belongs to the firm. Legal expenses cover on a caller's own policy may fund the matter. Not the same question.
- For a insurance brokerThe one question a broker's assistant can never answer, and the reply that still leaves the customer better off than silence would.
- For a mortgage brokerBuildings cover is a lender condition with a deadline. Life cover is a separate regulated sale. Neither gets advised on in a chat window.
- For a estate agencyA residential policy is rarely written for a let property, and rent guarantee turns on the referencing outcome rather than the landlord.
- For a marketing agencyCorporate procurement wants a limit and a certificate. What the assistant may confirm, and why it must never state a number.
- For a hotelWhether a cancelled trip is claimable sits between a guest and their insurer, and a car park notice is not the hotel accepting liability.
- For a holiday rentalA waiver is not a deposit and neither is insurance. What the owner's own cover does, and why the assistant never says a claim will be paid.
- For a driving schoolThe instructor's policy covers a pupil in that car and nowhere else. Practice in a parent's car is a separate arrangement entirely.
- For a plumbing and heating firmWhether a firm is registered and insured is published. Whether a home emergency policy pays for this repair is a question for the insurer.
- For a electrical contractorThis question is really two. One is about your liability cover, the other about the paperwork a solicitor will ask for years later.
- For a removals companyCustomers hear insured and think replacement value. Standard cover is a liability limit, usually per item, with exclusions that matter.
- For a car dealershipThree different policies get called insurance in one sale, and only one of them is the buyer's own, which is the one that gets the car off the site.
- For a fintech appSafeguarding and deposit protection are drafted statements, not a topic. Quote the paragraph, never summarise it, never reassure.
Questions
- Can it tell somebody whether they are covered?
- No, and it should be configured to say so plainly. It has no access to anybody's policy and no ability to read one. What it can do is confirm which insurers you work with, how billing runs, and exactly what the insurer will want before you can proceed.
- Is the acceptance question worth automating on its own?
- It is often the highest value answer in this whole intent. Which insurers you work with is stable, it is asked before almost every booking, and getting it wrong wastes an appointment slot as well as somebody's time.
- What should the refusal say?
- Name the decision maker and the next action in the same sentence. Coverage is decided by the insurer against your policy, here is the reference to quote them, and here is how to reach us once you know. A refusal that only apologises leaves the person exactly where they started.
Keep reading
- Handling refund requestsA refund question is really about eligibility and timing. What to index, what the reply may promise, and where it has to reach a person.
- Handling cancellationsCancellation content is hard to find on purpose. What it costs to answer plainly, how notice periods work, and what happens to data on the way out.
- Handling pricing questionsPublished price versus the price for this buyer. Bands, ranges and from pricing, and why a firm number for unscoped work is the damaging failure.
- Every question typeHandling patterns for the questions every support inbox gets.
Try it on your own material
Upload a document or point it at your site, paste one line of HTML, then ask it something only your business could answer.