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Master's Dissertation
DOI
10.11606/D.23.2005.tde-27092005-151120
Document
Author
Full name
Suely Rizzo Cavalcanti Cosentino
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2005
Supervisor
Committee
Cardozo, Hilda Ferreira (President)
Antunes, Jose Leopoldo Ferreira
Penna, Luiz Alberto Placido
Title in Portuguese
"Perícias de ressarcimento de danos em companhias seguradoras : análise da adequação dos tratamentos propostos, dos custos dos tratamentos e da documentação"
Keywords in Portuguese
avaliação de honorários profissionais
Epidemiologia do trauma
seguros de acidentes pessoais
Abstract in Portuguese
Os objetivos deste trabalho foram analisar as informações contidas nas apólices de dano à pessoa em processos de sinistros de seguradoras, e propor melhorias para o atendimento de traumatizados portadores desse tipo de produto. Foram descritas as informações sobre o perfil do segurado - sexo, faixa etária e ocupação -; características do trauma - como local e etiologia do dano -; características da lesão e dos tratamentos reabilitadores; adequação dos tratamentos propostos, dos honorários e da documentação. Foram elencadas as falhas detectadas nas apólices cuja documentação apresentava-se insuficiente. O estudo abrangeu 151 processos, dos quais 132 constituiam-se em Avisos de Acidente (iniciais) e 19 em Avisos de Continuidade. Quanto aos tipos de seguros, 124 eram de Seguro Escolar, 07 de Afastamento Profissional e 01 de DPVAT. Nos processos, 84 (63,64%) segurados eram do sexo masculino e 48 (36,36%) do sexo feminino; a faixa etária predominante foi a compreendida entre 6 e 10 anos, com 42 (31,82%) casos; o local de maior ocorrência foi a área escolar (57 = 43,18%). Na etiologia do dano constatou-se que 59 (44,70%) acidentes aconteceram durante locomoções, 34 (25,76%) em atividades lúdicas, 18 (13,64%) em práticas esportivas e 16 (12,12%) em ambiente doméstico, nos três últimos dos quais as quedas ocorreram com maior freqüência. Os dados de lesões referem-se tão somente aos Avisos de Acidentes, nos quais predominaram as fraturas coronárias simples, com 94 ocorrências, e 21 acidentes geraram lesões associadas de tecidos duros e tecidos moles. Da mesma forma, os tratamentos reabilitadores só contemplam os Avisos de Acidentes, nos quais prevaleceu a dentística (112). Na análise da adequação de tratamentos propostos, dos 151 processos, 133 estavam adequados e 18 inadequados. Quanto aos honorários profissionais, 89 apresentaram valores satisfatórios e 55, valores acima dos usuais. Os 7 processos restantes eram de Afastamento Profissional, nos quais não são avaliados os custos de tratamento e sim o tempo de restabelecimento. Em relação à adequação da documentação, 74 estavam adequados e 77 não completaram a documentação requisitada. Dentre os inadequados, a principal falha foi a ausência de radiografias iniciais e/ou finais.
Title in English
Damages compensation investigation in insurance companies: analysis of the suitability of treatments, their costs and documentation
Keywords in English
Assessment of Professional Fees
Insurance Policy for Personal Injury
Trauma Epidemiology
Abstract in English
This dissertation aims at analyzing the data on accident claims in personal injury policies from insurance companies and at proposing improvements on the treatment of injured people who hold this kind of product. The study describes information related to the insured profile (gender, age and occupation), to the trauma (such as the place and etiology of damage), the lesion and rehabilitation treatment characteristics, as well as whether proposed treatments were adequate for the fees charged and for the documentary evidence submitted. Errors identified in policies with insufficient documentation were also listed. The study encompassed 151 claims, 132 of which were Notification of Accidents (Initial Claims) and 19 were Notification about the Eligibility for Continuity of Care. As for the kinds of insurance, 124 related to School Accident Insurances, while 07, to Professional Leave, and only 01 related to Motor Vehicle Personal Injury Insurance. In those claims, 84 (63,64%) insured were male, whereas 48 (36,36%) were female; the main age group ranged from 6 to 10 years old, totalizing 42 cases (or 31,82%). Schools were the place where the greatest number of accidents (57 = 44,53%) occurred. In the etiology of damage, it was observed that 59 accidents (44,70%) occurred during locomotion movement, 34 cases (25,76%) in playing, 18 (13,64%) during the practice of sports and 16 (12,12%) at home. In the last three types, fall accidents occurred more frequently. As for the kind of lesion, the simple fracture crown prevailed in 94 cases, whereas in 21 accidents, it were hard and soft associated lesions. In the rehabilitation treatments, dentistry prevailed in 112 proceedings. As for the suitability of proposed treatments, out of 151 claims, 133 were adequate whereas 18 were not. As far as fees for professional services were concerned, 89 were considered satisfactory, while 55 were considered overcharged. The last 7 claims were related to Professional Leave, and so what is assessed is the time to recovery and not the treatment costs. In relation to documentary evidence, 74 claims submitted proper documents, while 77 did not. The latter main error was that initial and /or final radiographic documentation was not sent to the insurance companies.
 
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Publishing Date
2006-04-11
 
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