insurance Claims Management

Insurance Claims Management

Negotiation and correspondence on claims and delay in settlement of claims could be as costly in the long run as an outright repudiation of claims. To achieve a quick and full settlement of claims, proper care should be taken at the time of taking insurance to see that the risks are covered adequately and unambiguously on the lines discussed above.

Further, all policy conditions during the policy period and after the claim had arisen must be fulfilled. For this, the following are the important points to be considered:

Wherever there is a chance of the insurance cover

terminating before the materials reach the ultimate destination, written intimation to the insurer seeking an extension of the cover should be given.

1. Whenever there is a change in the ordinary course of the transit, written

intimation to the insurer would save a lot of trouble.

2. As stated earlier, it is a condition of a marine policy that the insured and their agents should preserve their rights of recovery against the carriers and bailees and transfer those rights to the insurer. Where this is not ensured the claim against the insurer is prejudiced.

3. The insured or their agents must claim on the carriers and on the Port Trust authorities for any missing packages according to regulations; and where they do appear to be damaged, a survey in the Docks must be conducted by a carrier’s representative and a claim should be lodged on the carriers In the case of rail and road transport open delivery certificates must be demanded and detained in the case of apparent damage to the consignment.

4. In no circumstances should clean receipts be given where goods are in doubtful condition except under written protest.

5. Notice in writing must be given to the carrier’s representative within three days of delivery if the loss or damage was not apparent at the time of taking delivery.

6. It is also essential that prompt written intimation of damage giving rise to a claim should be given to the insurer and a survey arranged. An insurer considers

7. a claim properly lodged and demanding their serious attention only when the documents such as original policy, bill of lading or railway receipt or lorry receipt,invoice, submission of relevant documents concerning the claim, survey report, claim bill, letter of subrogation are received by them.

Insurance Claims

     

An insurance claim is a formal request to an insurance company asking for a payment based on the terms of the insurance policy. The insurance company reviews the claim for its validity and then pays out to the insured or requesting party (on behalf of the insured) once approved.

The non-life insurance industry is witnessing shifting trends across policy administration and claims—the two core functions of insurance.

 The claims process is the defining moment in a non-life insurance customer relationship. To retain and grow market share and improve customer acquisition and retention rates, insurers are focused on enhancing customers’ claims experience.

 In a highly competitive insurance market, differentiation through new and more effective claims management practices is one of the most important and effective ways to maintain market share and profitability.

 In particular, insurers can transform claims processing by leveraging modern claims systems that are integrated with robust business intelligence, and document, and content management systems. This will enhance claims processing efficiency and effectiveness. It can benefit the insurers both operationally and strategically by enabling them to reduce claims costs to improve their combined ratio, improve claims processing efficiency, and drive customer retention and acquisition.

 Today in any insurance office the claim process is built on

• Claim document & content management tool
• Mobile based & smartphone-based technology solutions are the key
• STP processing to minimize delay
• Modern claim processing platform which is seamless & robust

 Normal claim process followed by General Insurers

• An insured or the claimant shall give notice to the insurer of any loss arising under the contract of insurance at the earliest or within such extended time as may be allowed by the insurer.
• Upon receipt of such a communication, a general insurer shall respond immediately and give a clear indication to the insured of the procedures that he should follow. In cases where a surveyor has to be appointed for assessing a loss/ claim, it shall be so done within 72 hours of the receipt of intimation.
• Where the insured is unable to furnish all the particulars required by the surveyor or where the surveyor does not receive the full cooperation of the insured, the insurer or the surveyor as the case may be, shall inform in writing the insured about the delay that may result in the assessment of the claim.
• The surveyor shall be subjected to the code of conduct laid down by the Authority while assessing the loss and shall communicate his findings to the insurer within 30 days of his appointment with a copy of the report being furnished to the insured if he so desires. Where, in special circumstances of the case, either due to its special and complicated nature, the surveyor shall under intimation to the insured, seek an extension from the insurer for submission of his report.
• In no case shall a surveyor take more than six months from the date of his appointment to furnish On receipt of the survey report or the additional survey report, as the case may be, an insurer shall within a period of 30 days offer a settlement of the claim to the insured. If the insurer, for any reasons to be recorded in writing and communicated to the insured, decides to reject a claim under the policy, it shall do so within a period of 30 days from the receipt of the survey report or the additional survey report, as the case may be.
• Upon acceptance of an offer of settlement by the insured, the payment of the amount due shall be made within 7 days from the date of acceptance of the offer by the insured. In the cases of delay in the payment, the insurer shall be liable to pay interest at a rate that is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by it.

How to Make a Claim under Motor insurance

A claim under a motor insurance policy could be

• For personal injury or property damage related to someone else. This person is called a third party in this context) or
• For damage to insured own vehicle. This is called an own damage claim and the insured is eligible for this if he is holding what is known as a package or a comprehensive policy.

Third-Party Claim

In a third-party claim, where the insured vehicle is involved, it is important to ensure that the accident is reported immediately to the police as well as to the insurance company. On the other hand, the insured is a victim, that is, if somebody else’s vehicle was involved, he must obtain the insurance details of that vehicle and make intimation to the insurer of that vehicle.

Own Damage Claim

In the event of an own damage claim, that is, where the insured vehicle is damaged due to an accident, the insured must immediately inform the insurance company and police, wherever required, to enable them to depute a surveyor to assess the loss. The insured must not attempt to move the vehicle from the accident spot without the permission of the police and the insurer.

Theft Claim

If P H's own vehicle is stolen, he must inform the police and the insurance company immediately. In addition, you must keep the transport department also informed. As soon as P H receives the policy document, he must read about the procedures and documentation requirements for claims.

If P H has to make a claim, he must ensure that he collects all the required documents and submit them along with the requisite claim form duly filled in, to the insurance company. There may be certain specific documentation requirements for specific types of claims. For instance, in respect of a theft claim, there is a special requirement that P H should surrender the vehicle keys to the insurance company.

Property insurance claim

There could be several types of policies that cover property and the property itself could be stationary - like a building, or moving around - like your household goods being transported.

P h on receipt of policy document must familiarize himself with the documents required for a claim as well as the procedures to be followed.

Whether or not a claim arises P H must follow the various dos and don’ts in respect of his property for the duration of the policy. These dos and don’ts are termed warranties and conditions in the policy document. In general, losses and damages, including those due to theft, fire, and flood need to be intimated to the relevant authorities such as the police, the fire brigade, and so on. It is important to ensure that P H must intimate the insurance company to enable it to send a surveyor for surveying and assess the loss.

Travel insurance claim

A travel insurance policy is generally a package policy that includes different types of covers like hospitalization, personal accident, loss/ damage to baggage, loss of passport, and so on.

The procedure and documents required for a claim would vary from cover to cover.

For ease of procedure and convenience, insurers normally attach the claim form with the policy document. This will contain the list of documents required in case of a claim and also the contact details including the phone numbers of the claims administrator either in the destination country to which you are traveling or in another country that is designated to receive and process your claim intimation.

Formalities for a health insurance claim

P H can make a claim under a Health insurance policy in two ways:

1. Cashless basis and
2. Reimbursement basis

On a Cashless basis: For a claim on a cashless basis, treatment must be only at a network hospital of the Third Party Administrator (TPA) who is servicing your policy. P h must seek authorization for availing the treatment on a cashless basis as per procedures laid down and in the prescribed form. He must read the policy document as soon as he receives it, to understand the claim process and not read it at the time claim arises.

Claims on reimbursement basis: P H must read the clause relating to claims in the policy document as soon as he receives it to ensure that he understands the procedure and the documents required for making a claim on a reimbursement basis. When a claim arises he should inform the insurance company as per the procedures required. After hospitalization, he has to ensure that he obtains and keeps ready documents such as claim form, discharge summary, prescriptions, and bills that he should submit for a claim.

Every insurer on their website clearly provides all relevant information relating to

• How to lodge a claim
• What documents are to be kept in possession
• Whom to be contacted to lodge a claim
• What information needs to be provided in lodging a claim
• Claim process adopted by the insurer
• How to follow up on claims lodged
• Help desk details to support customer service

This information is also included as part of the policy document in every sales brochure or communication.