5. CLAIMS MANAGEMENT Claims management means and includes all the managerial decisions and processes concerning the settlement and payment of claims in accordance with the terms of insurance contract. It includes carrying out the entire claims process with a particular emphasis on monitoring and lowering the claims costs.
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7. You need to identify and reject the invalid claims
14. The claims philosophy is defined as procedure or specified approach to settle the claims. It contains the claims management principles and also claims handling methods and procedures.
15. The claims process includes the basic claims procedure and handling of claims. The handling of claims includes the monitoring of situation or events, which cause the loss to the insured subject matter and give a cause to the insured to make a claim.
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18. Death claims. Maturity claims are payable as per the terms of the policy. These policies are generally endowment policies including money back policies. If the insured dies before the expiry of the term of the policy, it is called as death claim. The death of the life assured has to be intimated in writing to the insurer.
35. Survey ReportIn case of partial loss claims, submission of bills can be dispensed with for claims up to Rs.50,OO0 in respect of private cars and two wheelers only, subject to: o The Survey Report indicating the cost of parts allowed for replacement.
42. Through accident report from police in Form 54 prescribed under Central Motor Vehicle Rules, 1989.
43. Investigation: Investigation about the accident to collect the relevant data to quantify reasonable and just compensation as per the formats enclosed in respect of all third party claims is mandatory.
44. Appointment of Advocate: A competent advocate may be appointed if necessary to ensure that the proper defenceis taken where necessary and no frivolous statements are made.In the case where the fault of the driver is not proved, company should take immediate steps to deposit No Fault Liability amount as per section 140 of the MV Act, 1989.
48. PhotographsIt is considered preferable to appoint an investigator with surveyor’s license and knowledge of accounts as assessment of losses sometimes involves checking books of accounts.
58. Wherever the benefit of nomination is available to the proposer, in termsof the Act or the conditions of policy, the insurer shall draw the attention of the proposer to it and encourage the prospect to avail the facility.
64. The cost of claims will increase with the extension of time because the insurer may be asked to pay the interest on the unpaid insurance amount because of the delay. The court may direct the insurer to pay the costs of the case to the assured, which results in mounting up of costs.
65. The delay in payment may lead to litigation which is expensive.
73. Lack of motivation or knowledge about the importance of the claims settlement
74. Lack of awareness among the staff of the organizations or defective supervision
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77. Examining, inquiring, investigating, verifying and checking upon the causes and the circumstances of the loss in question including extent of loss, nature of ownership and insurable interest;
78. Conducting spot and final surveys and comment upon excess/under insurance etc
92. WHAT IS FRAUD ??? Insurance fraud is any deliberate deception/dishonesty committed against or by an insurance company, insurance agent, or consumer for unjustified financial gain. may be committed at different points in the transaction by different parties such as policy owners, third-party claimants, intermediaries and professionals who provide services to claimants. The fraudulent claims may be of two categories: The cause or the claim itself is fraudulent The claim may be genuine but the method of calculation or the evidences, or the information submitted may be fraudulent in nature.
93. FOR EXAMPLE : Creating forged documents such as wills, legal heir certificates, assignments of the policies and other papers to support their claim deliberate destruction of the insured subject with an intention to get the policy amount HOW IS IT DEALT WITH ??? As such any fraud made by the insured or the insurer in concluding the insurance contract or the claims settlement, makes the entire contract viocable at the option of the person on whom the fraud is played. The fraudulent claim by the assured will deprive him the right to claim as the insurer has the right to reject it.
94. CONCLUSION The success of claim management depends on the satisfaction of the customers. The customers are attracted to an insurance company by its state of art claim service.
95. One Final Thought… An experienced, competent claims team can’t on it’s own make your CI business profitable… …BUT… …An inexperienced, claims team can make your business unprofitable even if you have got the pricing and underwriting right. (and damage your brand at the same time)
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