Professional Documents
Culture Documents
Ch#3
Ch#3
CLAIM PROCEDURE
APRINCIPLES OF CLAIMS HANDLING APPLIED TO MOTOR INSURANCE
THE ROLE OF THE CLAIM DEPARTMENT The claim department had been described as the shop window of insurance compan . The claim handlin! can effect a polic holder"s decision as to whether the renew their current insurer or not. Therefore the role of the claim department is to# $ndemnif the polic holder in accordance with the co%er purchased. Ensure that onl %alid claims are paid. Pro%ide a fast& fair and efficient claim ser%ice. 'eal with the (Third Part claims whilst protectin! the polic holder interests. Protect the fund of premium a!ainst o%erpa ment& fraud and e)penses incurred due to inefficient claims handlin! processes Pro%ide a hi!h de!ree of ser%ice and also ensure that claims are %alid. Then *uantif accuratel each claim.
b its loss.
insured and mean that principle of indemnit had not been met. The insurer can reco%er from a third part after pa ment of claim onl . Pa ment that can be claimed is limited to the amount paid out under the polic . The insurer cannot reco%er from a third part before it has actuall settle6d its own insured"s claims. This is to be a !reat disad%anta!e b not ha%in! complete control of proceedin!& sa dela in action b the insurer a!ainst third part . To o%ercome this disad%anta!e& policies include a condition to pursue subro!ation before claim is paid. NOTIFICATION CONDITION
On the happenin! of an e%ent !i%in! rise to a claim under the polic & it is a condition to inform the insured promptl . CLAIM NOTIFICATION METHODES The followin! are %arious claim notification methods. An acci&ent re'ort (orm used to be the main method b which claims were notified to insurer. Now a da 4s ma+orit of claims are ad%ised o%er telephone. $f bro3er in%ol%ed. The are too as3ed to use this method. Also details of incidents can be entered strai!ht to computer. $nformation can also be obtained from the repairer /ome insurer pro%ides (statement o( insurance.1 The information pro%ided b the insured to be filled b the insurer and then sent to insured for completion and %erification. T e main 'ur'ose o( o!tainin% an acci&ent re'ort (orm or statement o( insurance are)* To pro%ide the polic holder with a con%enient medium throu!h which to ad%ise claim details. To ensure that all information pertinent to claims obtained earl and accuratel . Enable (%alidation1 of claims& that it is properl co%ered under the polic . To assist in dealin! with the claims *uic3l and efficientl . To pro%ide the polic holder4s current details in order to update underwritin! record.
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To chec3 to insure that the information disclosed at inception and 7or renewal was accurate and full. To assist in dealin! with liabilit issues. T e Main Hea&in%s containe& +it in t is (orm , to%et er +it t eir 'ur'ose, are as (o""o+s. POLICY DETAILS The polic detail identif the polic record and confirm whether it has recentl been incepted or renewed. POLICYHOLDER DETAIL These details are mainl re*uired that correct polic has been identified information alread held are correct. DRI-ER $f the dri%er co%er under the terms of the polic . $f the dri%er had permission from the polic holder to dri%e the %ehicle. $f not then the claim is not pa able -e ic"e.Motorc/c"e $s the 8ehicle of .otor C cle is the same co%er under the polic as per our computer records. $s there an modification in the %ehicle7motor c cle. Use o( t e 0e ic"e /ome time the use of the %ehicle is restricted. Therefore it is necessar to determent the use at the time of incident. Dama%e to t e 0e ic"e The dama!es must be consistent with the accident circumstances. Therefore inspection is re*uired.
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Detai" o( Acci&ent The accident must be within the polic period. Ot er 'art/ in0o"0e& 9or e)ample Third part in+ur or propert dama!e. $t helps in reser%in! and assessin! the loss. 1itnesses The e e witness helps to determine the responsibilities of occurrence. Dece"eration an& Si%nature This declares that the information supplied is true to the best of 3nowled!e and belief and pro%ides for the si!natures of the polic holder and possibl the dri%er. Ot er c"auses re"e0ant to c"aims Reasona!"e Care C"ause The polic holder to ta3e all reasonable steps to protect the %ehicle7motor c cle from the loss or dama!e and to 3eep it in a roadworth condition. Frau& C"ause $n common law& an polic tainted with fraud is :%oid4. A polic that is %oid in law is treated as thou!h it ne%er e)isted. A claim is fraudulent 0hich will includes !ross e)a!!eration /upported with the use of for!ed documents The polic holder would not ha%e an ri!ht to reclaim premiums paid. Co*O'eration C"ause Once an incident is notified& insurers will need the co-operation of the polic holder and or dri%er& who should pro%ide %er assistance. A&mission o( Lia!i"it/
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/hould the polic holder of the dri%er admit blame to a third part claimant then the position of the insurer ma be pre+udiced. The polic call for no such admission to be made. Ar!itration The polic calls for an dispute o%er *uantum that is the amount of claim& to be referred to an arbitrator before an le!al action can be ta3en a!ainst the insurer.
/uch repairers ha%e to be customer-focused and willin! to submit to *ualit standards. The ma also be a member of one of the reco!ni=ed %ehicle 7 motorc cle repairer or!ani=ation& such as -e ic"e Bui"&ers3 an& Re'air Association $ The labor rate is a!reed b the insurer with the repairer. $n case of replacement of parts& the price of the parts must be controlled b manufacturer4s price list.
The use of secondhand parts in %ehicle repair has been a feature in man countries for a number of ears and could be considered en%ironmentall friendl . Another source of competiti%el priced parts is that of non-proprietar parts i.e non-manufacturer. These are often made b the same companies that suppl %ehicle manufacturers and turned out on the same presses to the same *ualit .
SATISFACTION NOTE
At the time that the polic holder collects their car followin! repair& the will be as3ed to si!n what is normall termed a (/atisfaction Note ( The ob+ect of this note is to obtain the polic holder4s acceptance that the %ehicle had been returned in a satisfactor state and that the ha%e chec3ed and appro%ed the repair. 2ut this would not pre%ent the insured returnin! the %ehicle later the find an fault that had not been noticed followin! an inspection at repairers. >pon collection of the %ehicle& the polic holder will be re*uired to pa an a!reed contributions. These ma be of different t pes e.!. E)cess as shown in the polic 8AT where the polic holder is re!istered ta) pa er. An pri%ate wor3 carried out at the same time as the main repair An contribution for betterment.
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ROLE OF ENGINEER
The cost of repair authori=ed b an insurer is !enerall o%erseen b a team of en!ineers. The ma either be emplo ed in-house b the insurers or& The can be wor3in! for independent en!ineers and paid on a fee per case basis.
1OR2ING OF ENGINEERS
En!ineers will a!ree method and cost of each repair with !ara!e . The pro%ide repair authorit on behalf of the insurer. The will be a%ailable for consultation should somethin! chan!e durin! the course of repair and si!n off the final in%oice. $f repair is not economicall %iable then the en!ineer will declare the %ehicle an insurance write-off or Total <oss. The will calculate the pre-loss %alue of the %ehicle and& in some cases& will a!ree this with the %ehicle owner.
THEFT CLAIMS
Theft claims are sub+ect to different considerations to !eneral accident claims. There is a tendenc for man %ehicles reported to be stolen& to be reco%ered within a matter of da s or wee3s of the theft. $f the %ehicle is reco%ered in a dama!ed state& the insurer will proceed with the settlement of the claim in the usual wa . $f the %ehicle remains unreco%ered then the claim will be settled as per usual process. As such immediate notice of theft must be !i%en to the police authorit and also to the insurance compan . The followin! FEATURES must be considered for settlement of theft claim. 0e ha%e to see that
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A theft loss happened shortl after inception of the polic especiall where the co%er is onl Third Part 9ire and Theft. 0here the .OT Certificate E.inistr of TransportF e)pires shortl after the loss& or there is no .OT Certificate in force at that time. $f the %ehicle is co%ered under the term of the polic or there is other problem in the polic . 0here the location of the 3e at the time of loss or alternati%el misplaced. $n%esti!ations could be made b the sur%e or or assessor on the instruction of the insurer. $f the %ehicle is reco%ered in a dama!ed state& the sur%e or ma chec3 if there is an si!n of forced entr for e)ample one or more door loc3s had been dama!ed& then this certainl raised the possibilit that the theft is !enuine. 0hether there is e%idence that the i!nition loc3 dama!ed or wire tempered. Otherwise there is a possibilit that a 3e has been used to ta3e the car. $f the insurer is satisfied that the %ehicle is not reco%ered& then it will normall wait a set or period before settlin! the %ehicle as ha%in! been stolen :permanentl 4. The insurer will ha%e settlement four or at the most si) wee3s& before dealin! with the claim. $f the %ehicle is subse*uentl reco%ered it will either be treated as /A<8A?E belon!in! to the insurer OR the claims mone will be re-paid and the %ehicle re%erts to the insurer4s ownership. This option is hardl e%er used in practice.
FIRE CLAIMS
The moti%e for such claims ma be %arious# The %ehicle ma not ha%e been in particularl !ood condition. The insured ma ha%e failed to obtain .OT Certificate. $t ma be that the ma3e and model of the car is undesirable perhaps due to its a!e and condition etc. 9or the polic holder& submittin! a spurious fire claim is preferable to bein! left with a car which would fetch little if sold on the open mar3et. 9ire claims comprise a small proportion of the total claims portfolio of an insurer and some fire claims are perfectl !enuine.
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$t is often the order car that is prone to such a loss due to the parts becomin! worn out and in particular& electrical wires becomin! fra ed or worn. Howe%er& the actual item or part that brea3s down will be e)cluded.
MAR2ET -ALUE
$t is the amount that it would cost to replace the %ehicle with one of the same ma4e& mo&e" and a%e& and in the same con&ition and with mi"ea%e is the mar3et %alue of that %ehicle.
SALE OF SAL-AGE
$f a claim is bein! settled on a total loss basis& then the insurer will retain the /A<8A?E and will sell it to offset costs. in%ariabl
Howe%er& motor %ehicle sal%a!e is& unfortunatel & the sub+ect of fraud on occasions. $t can be ta3en and used on stolen %ehicle. $t is for these reasons that the insurance industr & in con+unction with the bu ers and ?o%ernment departments& has sou!ht to control the disposal of sal%a!e. All sal%a!e reco!ni=ed in accordance with !uidelines issued b the '8<A. The cate!ories ran!e from :A4 to :'4. The cate!ories :'4& the lowest cate!or %ehicles are reported to the '8<A and the will enforce rules to ensure either no further re!istration of a %ehicle of re!istration documents is !ranted. To further safe!uard a!ainst fraud& $nsurers re!ister& throu!h A2$& all the total loss and thefts on an industr computer 3nown as .$A9TRE .otor $nsurance Anti 9raud and Theft Re!isterF database. An cash settlement will be made to an 3nown finance compan that has an outstandin! hire purchase or lease a!reement on the %ehicle. $n practice& this will occurs where the %ehicle is bein! treated as a total loss. /al%a!e companies b %ehicle upon the probable profit mar!in from resale either
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as a whole or as parts.
CONTRIBUTORY NELIGENCE
The present law on contribution ne!li!ence <aw Reform E Contributor Ne!li!ence F Act&,D6; which states that a person"s dama!es will be reduced b an amount which is "+ust and e*uitable" ha%in! re!ard to person"s e)tent of responsibilit for the occurrence. That is the amount of reduction will be commensurate with the e)tent of their responsibilit . 9or e)ample#Pa!e#,5 of ,-
The speed of both the %ehicle will ha%e to be considered. The manner of the dri%in! of the parties and their reaction time will be ta3en into account. Road conditions /tate of weather. 0hen seat belt is not utili=ed 9ail to wear crash Helmets. .isleadin! si!nal b the dri%er on the main road.
Con&uctin% t e c"aims
The insurer ma re*uire more detailed e%idence of the location of incident. 0hene%er there is a claim for personal in+ur . A medical e)amination of the claimant is essential b a doctor nominated b the insurer.
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1ITHOUT PRE5UDIC
The e)pression " without pre+udice " means that An action ta3en or an opinion !i%en is not to be construed as an admission of liabilit . Correspondence mar3ed " without pre+udice " cannot be produced as e%idence in the le!al proceedin!s. This means that ne!otiations ma be underta3en freel .
CLAIM AND UNDER1RITING E8CHANGE The A2$ to!ether with E*uifa) decided to establish a series of re!isters 3nown as C>E . $t was intended that data %ase would contain information on all claims for different classes of insurance. A number of insurers ha%e decided to use C>E at inception& thus defeatin! nondisclosure and & possibl fraud e%en before co%er is !ranted.
NORTHERN IRELAND PERSONAL ACCIDENT REGISTER The insurer in Northern $reland are encoura!ed to re!ister details of persons claimin! personal in+ur from motor accidents etc. A match report will then be issued in the same wa as .$A9TR and C>E. MOTOR INSURER DATABASE $t pro%ides a list of all the %ehicles normall in the >B& plus the names and addresses of the re!istered 3eepers& to!ether with the correspondin! re!istration plates. Additionall the database incorporate particulars of each insurance polic that relates to %ehicle& includin! & the polic number& plus full detail of insurers& it also includes particulars of these %ehicles which are used on a road or other public place& but are not re*uired to be the sub+ect of insurance. The detail of bodies of indi%iduals who are responsible for compensatin! an in+ured third part mist also be recorded. At the moment& there is a ma)imum of ,6 da s allowed for an chan!e and the .$' details bein! amended. This will reduced to A da s& and the idea is that it will be updated in real time. FINANCIAL OMBUDSMAN SER-ICE
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The insurance Ombudsman 2ureau E$O2F was formed in ,DC3 to pro%ide personal insurance polic holders with an independent bod that could arbitrate on disputes without cost to the indi%idual. 9ollowin! the enactment of the financial /er%ices and .ar3ets Act&5GGG& the insurance ombudsman came part of 9O/ under the control of 9inancial /er%ice Authorit . .embership of the 9O/ is compulsor for all authori=ed insurers with e%er compan re*uired to participate and contribute funds to its operation.
The 9O/ is an entirel independent mechanism for dealin! with disputes. The Ombudsman onl deals with disputes where the insured is either a pri%ate indi%idual or a small commercial enterprises ha%in! a turno%er of less that Pound , .illion. $t is not concerned with commercial insurance for lar!er enterprises. The scheme onl operates where the dispute is between and insured and an insurer. The ombudsman aims is to pro%ide both impartial and independent conciliation of disputes between these two parties. The ombudsman ensures that all possible steps are ta3en b the insurance compan itself to tr to resol%e the dispute. $f the dispute remain unsol%ed& the ombudsman then steps in to re%iew the dispute and ma3e a decision. The ma)imum award which the ombudsman can made which is bindin! on the insurers is Pound ,GG&GGG. Acceptin! the decision results in the insurer bein! re*uired o pa an award & up to a monetar limit. The insurer is bound to b the ombudsman"s decision. The insured can either accept or re+ect the ombudsman"s decision. $f the insured re+ects the decision& the insured can still choose to issue le!al proceedin!s. Chapter No.3 Closed
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