Claims Management

Claim is a right of insured to receive the amount secured under the policy of insurance contract promised by Insurer. Beneficiary depends on the following conditions: Nomination Transfer Assignment

Operative clause
The operative clause in the policy document mentions the mutual obligations and responsibilities of both the parties.
Event on the happening of which benefits are payable where the policy is in full force, death benefits, survival and maturity benefits. To whom the sum assured is payable. Period during which premium is payable. Details hen premium payable

Amount Payable
The amount insured or face value of policy Bonus if declared by company Share of profit in case of participation policy Surrender value if policy lapsed

Claim procedure
 You file a claim and supply necessary documents The first step in an insurance claim settlement is to communicate with your insurer, fill out the insurance form and send it with the required documents.  Adjuster assesses the situation and gives an estimate
 Insurance adjusters  Claims examiners  Insurance investigators

 Your insurance claim is settled

 As per the regulation 8 of the IRDA (Policy holder's Interest) Regulations, 2002, the insurer is required to settle a claim within 30 days of receipt of all documents including clarification sought by the insurer.  However, the insurance company can set a practice of settling the claim even earlier. If the claim requires further investigation, the insurer has to complete its procedures within six months from receiving the written intimation of claim.

Claim payment on Death

Procedure of claim settlement
Letter of intimation of death including
Proof of age Death certificate Policy number and name Name and address of claimant

 Internal enquiry when notice received

Any dues pending. Policy status lapsed or running. Exclusions & inclusions of that policy Nomination, assignment or transfer. Cause of death. Place of death. Hospitalization details (if any). Statement of Doctor & hospital Statement from organization where the person is working

 For unnatural death accidents or suicide etc

FIR post mortem chemical analysis report Copies of Medical Records, Test Reports, Discharge Summary, Admission Records of hospitals and Laboratories.

If original death certificate not available, then alternative proofs considered such as Death in air crash Disappearance on board a ship

Presumption of Death if not seen for seven years

Claim payment on maturity

Procedure for Claim settlement On the date of maturity life insured is required to send maturity claim / discharge form and original policy bond well before maturity date to enable timely settlement. Most companies offer/issue post dated cheques and/ or make payment through ECS credit on the maturity date.
Policy document submission Age Proof Internal enquiry Original Deed of assignment (if any) Other documents (Receipt of Payment etc )

Disputes in claims
Identify the person to whom the payment is to be made
Whether the payment is within the terms of policy Whether the amount claimed is reasonable Proof of Death

Identification of assignee, nominee or the legal heir to whom the payment is to be made

Settlement of claim
Settlement within 30 days if no Dispute and 10% interest as penalty for delay.
In case of dispute, company can apply to court within ninety days on following circumstances:
When there is conflicting claimants When there is insufficiency of proof When there is any other adequate reason

HEALTH INSURANCE CLAIMS

To provide prompt claims servicing a company may appoint Third party administrator duly licensed by IRDA. The TPA will provide you the services in a hassle free manner within the terms and conditions of the Health policy. They will provide you the following claims services:
"Cashless Service" at all our Network Providers for all eligible ailments/conditions. Processing and settlement of claims under the MEDICLAIM policy with a time bound approach. 24 hours Call Centre Service.

Claim Procedure: Claims are broadly of two types:

Reimbursement Claims Cashless claims.

Claims under the above categories can be further of two types: Planned Hospitalization & Emergency hospitalization.

Procedure for Reimbursement Claims: To avail inpatient hospitalization services, you can go to any hospital of your choice, either a hospital on our network or a hospital outside the network. The difference between the two being that TPA can authorize for "Cashless Service" in the hospital on our network whereas you will have to settle all the bills in the hospital which is outside our network. However you have to follow the procedures listed below to get the services in different situations. A) Emergency hospitalization Step 1. Take admission into the hospital. Step 2. As soon as possible, inform TPA about the hospitalization. Step 3. At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports. Step 4. Lodge your claim with TPA for processing and reimbursement. B) Planned hospitalization Step 1. Inform TPA about the planned hospitalization. Step 2. Get admitted into the hospital. Step 3. At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports. Step 4. Lodge your claim with TPA for processing and reimbursement.

Procedures for Cashless Claims: Cashless Service is the service wherein you need not pay any amounts either as a deposit at the time of admission or for the hospital bills at the time of discharge. This facility is available only at our Network Hospitals. To avail the "Cashless Service" you need to fill "Cashless request form" available in the network hospital get an authorization from TPA. This authorization along with a copy of the card issued by TPA has to be given to the Network Provider at the time of admission. Please Note: TPA will authorize "Cashless Service" at the Network Providers in all cases eligible under the insurance policy. "Cashless Service" may be denied in some of the situations as listed below.

In case of any doubt in the policy terms with respect to the present ailment. If the information sent to TPA is insufficient to confirm coverage. The ailment/condition etc. not being covered under the policy. If the request for preauthorization is not received by TPA in time. Denial of "Cashless Service" is not denial of treatment. You can continue with the treatment, pay for the services to the hospital, and later send the claim to TPA for processing and reimbursement.

 Auto Claim Procedure: Claims are broadly of three types:

Own damage Claims Theft claims. Third party Claim

Contact insurance company to intimate the claim with in 24 Hrs of the accident Mention the policy No /vehicle no to intimate the claim Please don't leave the vehicle unattended/unlocked after the accident, if there after any theft of parts or accessories will not be honoured by the company. If there is any leakage of oil or coolant or any major accident, please don't drive the vehicle, as any extension further to the damages will not be covered under the policy Take the vehicle to the nearest authorized garage of your choice / preferred/Cashless Workshops of Reliance General Insurance co. ltd. Leave a copy of Driving License who was driving at the time of accident, RC Book copy duly self attested along with the duly filled and signed claim form in the garage. Don't start the repairs without Survey/Inspection of Reliance general Ins Pay the difference in the case of Preferred Ws or Cashless garage and take the delivery of the vehicle .( Pay the full amount if the vehicle is repaired at the Workshop of your choice which is not listed in our cashless/preferred Garages and send the bills & receipt to us for reimbursement). if the Bills are above 20000/- reinspection is to be done. In case of Commercial Vehicles, Please inform our Call centre immediately after the accident so that we can arrange for a spot survey on the accident spot. Vehicle can be shifted to the garage after the spot survey is conducted and should inform the company about the garage details so that company will appoint the surveyor to assess the loss. In case there is third party involvement FIR is must. Additional document in specific claim shall be intimated separately.

FIRE INSURANCE CLAIMS

IMMEDIATE ACTION AFTER LOSS: Take measures to extinguish the fire and all steps to minimize the extent of loss. Inform the Fire Brigade and co-operate with them but don't forget to; Obtain the Fire Brigade Report and bill for fire fighting expenses, because these expenses are payable under the policy. Intimate the insurance company with a rough estimate of loss as early as possible and obtain your claim form, before 14 days of the loss. In case of damage due to natural calamities like storm, floods, lightning, obtain the meteorological report for the weather broadcast at the time of disaster. Do not dispose the Salvage until advised by the surveyor or Insurance Company.

Document Check list Basic Documents:

Claim Form duly filled in & signed. Claim bills : Detailed claim bills with necessary bills/vouchers. F.I.R, if filed. Fire Brigade Report (internal or external or both as the case may be). Forensic Departments report, if applicable. Laboratory test report together with the mandate given, if applicable. Record of Labour involved in activities related to claim. Original Repair/ Replacement Bills with receipt. Photographs if arranged. Departmental Note on the incident. Meteorological report: In case of natural calamities like floods, cyclone, earthquake etc) or News paper cutting.

Marine Insurance
CLAIM PROCEDURE
In Marine Insurance claims, all the documents of the claim is to be submitted to the insurance company. The documents should be submitted in original. Wherever original documents are not available second copy / printed copy may be accepted but photocopies are not acceptable. The documents are to be submitted preferably in one lot and within reasonable time limit of occurrence of the claim and under all circumstances before claim becomes time barred against carrier etc. The following is a list of claim documents, which is generally required for any marine claim. The insurance company may ask depending upon the nature of claim other additional documents.
A. OCEAN TRANSIT: Inland Transit (Road and Rail) Air Transit Postal Transit

Basic Documents Required:

Claim Form duly filled in & signed. Original Policy/Certificate. Short Landing Certificate/Landed But Missing Cargo/Damage Certificate (as applicable). Suppliers Invoice Packing List. Quadruplicate copy of Bill of Entry. Steamer Survey report in original.(if arranged) Copy of Claim Notice served on Carrier/Port authorities along with postal acknowledgement card. Copy of correspondence with the carrier/Port authorities/Customs authorities. Copies of Correspondence exchanged with the suppliers (reply from suppliers is a must)in connection with short packing (if applicable). Lost Overboard Certificate from the Port Trust countersigned by the master of the vessel or steamer agents (in respect of Loss Over Board /Sling Losses). Original Repair Bills with receipt/Proforma Invoice for value of items lost/damaged. Copy of Application filed with Customs for refund of Duty (if applicable). Photographs if arranged. Letter of Subrogation cum special power of Attorney.

BURGLARY INSURANCE CLAIM IMMEDIATE ACTION AFTER LOSS: You should inform the Police authorities immediately with a formal written complaint and obtain a copy of the FIR (First Information Report) which has to be given to the insurance company. This is a very important document required for processing your claim. Intimate the insurance company with a rough estimate of loss as early as possible and obtain your claim form. The insurance company will not be liable for any loss or damage, if the loss is not intimated to them within 14 days. In case of small claims upto 2500/- we directly settles the claim on the basis of your completed 'claim form' and the 'Police Report'. For claims above Rs. 2500/- a surveyor is appointed by the insurance company to investigate your claim. CLAIMS PROCEDURE Basic Documents:

The Police Report: It should include copies of your written complaint to the police and the FIRST AND FINAL INVESTIGATION REPORT (FIR). Claim form: Duly filled and completed in all respects. Claim Bill: Detailed claim bill with necessary bills and vouchers. Documentary evidences about the value of property stolen through invoice, bill, books of account etc. Final Survey Report: As made by the surveyor. Copy of your Burglary Insurance policy certificate. Letter of Indemnity: You should provide a letter of authority in favour of the insurance company if there is any right of recovery. Photographs, if any.

Surveyors/Loss Assessors
They investigate, manage, quantify, validate and deal with loses arising from any contingency and report thereon. Surveyors are professionals who assess the loss or damage and serve as a link between the insurer and the insured. They usually function only in non life business. Their job is to assess the actual loss and avoid false claims. Surveyors like agents, are not employees but are independent professionals hired by the insurance company. Report should be submitted not later than 30 days and period can be extended with consent of the insured and insurer in exceptional cases.

Role of Surveyors
A person intending to act as a surveyor and loss assessor (S& LA) in respect of general insurance has to apply to the Insurance Regulatory and Development Authority (IRDA) for the grant of license to act as such in: i. FORM-IRDA-1-AF, if the applicant is an individual; or ii. FORM-IRDA-3-AF, if the applicant is a firm or company In particular and without prejudice to the foregoing, the Authority shall satisfy itself that the applicant, in addition to submitting the application complete in all respects: satisfies all the applicable requirements of section 64UM read with section 42D of the Act and rule 56A of the Insurance Rules, 1939; possesses such additional technical qualifications as may be specified by the Authority from time to time; has furnished evidence of payment of fees for grant of license, depending upon the categorization; has undergone a period of practical training, not exceeding 12 months, as contained in Chapter VII of these regulations; and furnishes such additional information as may be required by the Authority from time to time.

Duties and responsibilities

Declaration of interest in the subject matter. Maintenance of confidentiality and neutrality without jeopardising the liability of the insurer and claim of insured. Conducting inspection and reinspection of the subject matter. Examining, investigating and verifying upon the causes and the circumstances of the loss and the extent of the loss. Conducting spot and final surveys. Estimating, measuring and determining the quantum of loss. Advising the insurer and the insured about loss minimization and security and safety measures to avoid future loss. Commenting on the admissibility of the loss and also observance of warranty conditions Surveying and assesing the loss on behalf of the insurer or insured. Assessing the liability Pointing out discrepancy in the policy wordings.

Role of Surveyors
Insurance risk surveyors carry out surveys of buildings, machinery, transport and other sites or items that need to be insured. A key part of the work is to produce reports, to help an agent who sells insurance, decide on the terms and conditions of insurance policies. Insurance surveyors usually specialize in one of the following areas: fire and perils examining plans, construction and fire protection systems to assess the risks to a building and its contents accidents and liability assessing the possible risks to employees, customers and visitors to a building or site engineering insurance surveying mechanical and industrial plants, machinery and equipment for faults and risks burglary and theft inspecting business premises to check how goods are stored and improve security. The insurance business operates on the principle of indemnity, and as there is a tendency on the part of customer, to benefit out of an insurance transaction, the surveyor puts a check on that and assesses the loss. He then gives a report to the insurance company and based on the surveyors report the company will settle the claim. But in todays scenario it as seen that the insurance company tries to ignore the report submitted by one surveyor and keep on appointing surveyors one after another unless they get favorable report.

Claims adjusters investigate insurance claims by interviewing the claimant and witnesses, consulting police and hospital records, and inspecting property damage to determine the extent of the companys liability. In the United Kingdom, the Republic of Ireland, Australia, South Africa, the Caribbean and New Zealand the term Loss adjuster is used. Claims adjusters have the knowledge to complete the preparation of a property damage claim which, to an unrepresented homeowner, may be unfamiliar territory. The documents contain technical terms such as depreciation, replacement costs, and actual cash value, that may be unknown to the policyholder, and a trained claims adjuster can ensure a correct completion. There are several classes of claims adjusters:
staff adjusters (employed by an insurance company or self-insured entity), independent (independent contractors; not insurance company employees) public adjusters (employed by the policyholder). Claim Service Representatives (employed by the Insurance Company, or Independent Adjusting Company).

Specific duties include: Responding to claims in a timely manner Filing paperwork Communicating with policy holders Investigate liability Assess damages Research, detail and substantiate each aspect of the claim, including building damage, contents, and extra living expense claims. Negotiate with product/service providers on time and cost of repairs for the purpose of making an offer of settlement to the insured. Ensuring accurate procedures Protect the interest of the insurance company the adjuster represents, when dealing with claimants. Computer Skills with a high degree of proficiency.

 An arbitration clause is a commonly used clause in a contract that requires the parties to resolve their disputes through an arbitration process. Although such a clause may or may not specify that arbitration occur within a specific jurisdiction, it always binds the parties to a type of resolution outside of the courts, and is therefore considered a kind of forum selection clause.

 The arbitration process is often used by insurance companies when two parties have a dispute over fault and/or damages The dispute can be for one of those factors or for all of them.
There can be dispute as to who is at fault (or what percentage of fault should be attributed to each of the parties), or a dispute of how much your medical bills should be, or the amount of your rental car bill, or all of it together.

Arbitration occurs after both insurance companies have conducted an investigation of the facts and they cannot agree on those facts, and their implications.

 Where there is no witnesses often ends up in arbitration. A common dispute is the red - green light dispute. Each insurance company is obligated to believe their insured unless there is independent evidence against her (a witness or a police report). Because each carrier has this duty (and if they do not obey this duty, they can be acting on bad faith), they must take this matter to arbitration.

 Arbitration is a pre-agreed forum to resolve a dispute. Example: In the case of car accidents, insurance companies that are members of the National Association of Arbitrators (they pay a fee for this membership) agree that the decision of the arbitration panel will be final. There will be no appeals, no arguing, nothing else. The arbitration decision is binding upon the insurance companies, even if the decision is believed to be a bad one or even if new evidence comes up, the decision will still stand. Arbitration really is a contract between the parties (between insurance companies and between the insurance company and the insured) to a pre-agreed mediation.

 This is important because it has implications on whether or not an arbitration decision is binding or not. Arbitration is conducted by a panel of independent claim adjusters. Independent, in this context, means being related to neither of the insurance companies involved in the dispute. These panels are usually formed of one arbitrator, but sometimes (and in more difficult claims) up to three arbitrators.

 These adjusters are usually considered more experienced in their fields and are supposed to be unbiased, Both the parties need to understand the arbitration process so that they do not end up with an arbitration decision that one does not like. Unfortunately, consumers and insurance companies take no part in the selection of the panel. Insurance adjusters are encouraged to settle among themselves because the arbitration process does cost the insurance company money. Often, it costs them a lot less to settle over the telephone, than putting an entire arbitration file together. However, the arbitration cost is significantly less than an actual court case. So, arbitration is rather common among carriers.

Claim No: ..

DISCHARGE VOUCHER I/WE have this day taken delivery of Motor Registered No . and hereby certify that the whole of the repairs and replacements for which I/we have claimed have been carried out to my/our entire satisfaction by . I/We hereby authorize and direct NEW INDIA ASSURANCE COMPANY LIMITED to pay the accounts for such and such and such payments will discharge NEW INDIA ASSURANCE COMPANY LIMITED from all liability in connection with my/ our claim for damage to such motor vehicle arising out of accident which occurred on: . (date) .. (month ) . (year ) Signature of Insured: . Witness: .. Date: . N.B.No aacount recognized unless accompanied by this discharge voucher.