4. Claims handling procedures and related claims service
Understand claims handling procedures and related claims services.
1. Know claims handling procedures for motor policies.
2. Know claims handling procedures for household policies, gadget policies, travel policies and extended warranties.
3. Know claims handling procedures for commercial property and pecuniary policies.
4. Know claims handling procedures for commercial liability policies.
5. Know claims handling procedures for health policies.
6. Know the Civil procedure rules.
7. Know how the Ministry of Justice portal works.
Claims handling procedures and related claims services:
When a claim is notified to an insurer, the response will depend on the type of claim as well as the extent of damages. Example, a liability claim could take 2 years to settle while a motor accident with a slight bumper damage could result be settled in days.
Claims flowchart:
notification –> review –> response to claimant –> claims investigation
|
review <- recoveries <- claims settlement <- Claims negotiation
Personal Insurance:-
a. Private motor claims – cars and motorcycles
b. health – personal accident and sickness
c. household –contents and buildings
d. travel
e. Extended warranty
f. Pets
a. Private motor claims – cars and motorcycles
The considerations for both cars and motorcycles are the same subject to certain policy differences.
Note seven aspects to the claims process:-
1. The insured is bound by the claims notification condition to report ALL claims whether you are
making a claim or expecting a third party to claims against them
2. At notification, the insured may be required to complete an Accident Notification Form (ANF) which
could be done over the telephone or internet.
3. When the insurer has received the information, the insurer will set up a file, this could now only be
an electronic document , not necessarily a paper file.
4. If a claims is to be made, the insurer will first check to see if the claimant is entitled to an indemnity.
Depending on the nature and size, it may be investigated. This could be done as a desktop exercise or sent
to a loss adjuster who will interview the driver and witnesses etc. A visit to the place of the accident may be done. Valid claims are settled, The insurer usually used THEIR own authorized repair centers.
a. Private motor claims – cars and motorcycles cont’d
The considerations for both cars and motorcycles are the same subject to certain policy differences.
Note seven aspects to the claims process:-
5. If there are claims under other sections of the policy (eg: property damaged in the vehicle) reviewed
as necessary
6. A third party(TP) may claim for a vehicle or damage to other property such a s a boundary fence or hedge.
The TP will generally be required to submit estimates for repair or replacement for the damaged item.
The insurer will approve or renegotiate, establishing fault or degree of damages for each party. If the
insured was fully responsible; the insurer may offer to proactively settle TP claim to control costs.
7. If a TP is injured in the accident, claims can be complex and costly to settle. The degree of negligence must be
established before consideration of the extent of the injury, the medical prognosis and other relevant
considerations (whether the claimant is unable to work or had required care whilst incapacitated). A claims
handler must be able to analyses this information and place an accurate valuation against the injuries in line with
current court damages awards, then settlement can be agreed.
Note: If the insured has a non comprehensive cover (eg, TP, TPFT, RTA), the policy condition requires that such incident must still be reported to the insurer, even though the insurer will take no further action.
Health Claims
The considerations are for personal accident and sickness policies .
1. These are benefit policies and not indemnity policies hence settlement can be quick as the amount to be paid was
already agreed at policy inception.
2. When a claim is submitted, insurer will carry out the usual compliance check eg: Was the policy enforced and has
the policy conditions been complied with etc.
3. Supporting evidence such as:
i. Death from an accident or injury – Coroners inquest, postmortem examination, death certificate
ii. Loss of Limb or Limbs – sufficient proof must be provided
iii. Temporarily or Permanently disabled – medical certificate is required and insured under the care of a
registered doctor.
iv. The insurer may wish to consult with their own medical expert to verify the extent of any illness or disability
c. Household Claims
Contents:-
i. Durable goods (fridges, stoves) – settled on a NEW FOR OLD basis, hence replacement item.
ii. Consumer goods (towels or drapes) – either on a new or old or an indemnity basis.
Buildings:-
i. Settlement usually by repair. There is an element of Betterment. An indemnity is the cost of repair or
reinstatement at the time of the loss less an allowance for betterment. An adjuster can be used to help.
ii. Examples of betterment – Double glazed windows (single glazed was damaged), New electrical wiring.
Travel Insurance Claims
The considerations will depend on the section of the policy where the claim is brought as follows:
1. Personal Accident & Sickness – same considerations will apply as in PA & Sickness claims in the earlier section.
2. Travel interruption or delay – The insurer can make its own enquiries or ask the insured to provide proof
3. Medical and Associated Expenses – usually prior authorization is required to control costs. Emergency medical
expenses claims are scrutinized prior to payment.
4. Baggage Personal Effects and Money – Proof of purchased of the items plus that the loss was reported to the
authorities.
e. Extended Warranty Insurance Claims
i. Claims are via a repaired item or replacement. No issue with fraudulent claim as a result
ii. A claim form is not usually required, and a telephone call may be sufficient to the issuing company
is all the insured may be required to do.
iii. Issuing company will attend to the repair and an excess is required.
f. Pet Insurance Claims.
i. The cover is for injury, loss and or illness of a domestic family pet.
ii. Vet fees are covered for accidental injury or illness
iii. Theft – reward
iv. Boarding fees
v. euthanasia costs
vi. In the case of dogs – Liability for biting third parties.