Intraoperative injury identified and actioned: third-party recovery pursued following complex pelvic surgery

Case 2  ·  Patient Level  ·  United Kingdom

WHERE WE STARTED

A UK private health insurer was processing claims for a patient who had undergone complex multi-organ pelvic surgery for endometriosis. Within days, the patient was back in hospital — sigmoidoscopy, laparoscopy, upper GI endoscopy, repeat ureteric stenting — with three different surgeons involved over several weeks. Each claim passed individually. The picture they formed together was not being read.

THE CHALLENGE

The insurer’s claims processing system assessed each claim on its own merits. The clinical logic for each individual procedure was defensible. What the system couldn’t do was look across a patient’s full journey and ask: does this pattern, in this sequence, at this pace, represent something going wrong?

What had already been tried:

The clinical team had no automated mechanism to detect post-operative complication patterns in real time. The volume of claims and the complexity of the clinical picture meant that by the time a human reviewer might have noticed the pattern, several further interventions had already been authorised and paid. Critically, no process existed to identify whether the complication pattern pointed to a third-party liability — meaning potential recoveries were being missed entirely.

HOW KIRONTECH FOUND IT

• HIP mapped the patient’s full claims journey chronologically, identifying the unusually compressed timeline between the initial major surgery and the cascade of follow-on interventions.
• The pattern — colorectal, urological, and upper gastrointestinal investigations in rapid succession — was flagged as consistent with a significant intraoperative complication, most plausibly involving bowel or urinary structures.
• The need for repeat ureteric stenting and subsequent cystoscopy, alongside multiple imaging studies, was identified as consistent with a prolonged and complicated recovery rather than expected post-operative care.
• HIP’s patient-level view surfaced a pattern that no single-claim review would have detected — and identified the liability indicators that enabled a third-party recovery to be pursued.

WHAT CHANGED

This case prompted the insurer to rethink how it manages complex surgical claims — and what those claims might be worth beyond their face value. Rather than reviewing procedures individually, the clinical governance team now receives alerts when a patient’s post-operative trajectory deviates from expected norms. The shift — from reactive claims processing to proactive patient monitoring with third-party recovery capability — is a direct result of what HIP surfaced here.