m To protect against un-foreseen events

mTo indemnify losses

mTo pay claims

laim is a right of insured to receive the
amount secured under the policy of
insurance contract promised by Insurer.
laims 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.
m 2ou need to identify and pay the valid claims

m 2ou need to identify and reject the invalid claims

m Mistakes cost money and impact on brand

m laim settlement can be used as a marketing tool

m laims 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.

m 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.

m 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.

m The claims handling is the integrated part of the claims management

and executes the decisions made by the claims management machinery of
an insurance company.
Oife insurance is broadly categorized as
m Maturity claims
m 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.
Marine insurance claims can be broadly
categorized into -

mMarine cargo
mMarine hull
mOcean going vessels
mSundry hulls
The main documents generally required for processing
fire claims are:-

m laim form duly completed by the insured.

m opies of the policy complete with terms, conditions
and warranties.
m Photographs (if necessary)
m Police report and (if necessary)
m Fire brigade report (if necessary)
m Where the loss estimate is more than Rs. 1 crore,
intimation is to be sent to tariff
m Advisory committee ( TA )
Motor insurance claims are broadly categorized into:

1. Own-Damage claims, and

2. Third party claims.

Own-Damage claims-

Immediately on receipt of intimation of loss, either in

writing or over telephone, a surveyor should be appointed
based on the estimate of repairs.
 The documents generally required for settlement of motor
claims are:
m Photographs of the vehicle at the spot of the accident,
showing all
the external damages and the number plate of the vehicle.
m laim form duly filled in.
m Registration ertificate
m Driving Oicense
mOoad hallan/Trip Sheet
m Fitness ertificate
mopy of the FIR
m Survey Report

In 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.
Theft claims are either total loss claims or partial loss claims. If
claims settling authority is not fully satisfied, investigation of
the theft to be arranged by an investigator who may be
appointed with specific terms of reference.

The following documents should be collected from the insured

in addition to a certified copy of FIR:

m Surrender of the Registration Book and the Tax Book to the

insurer duly transferred in the name of the insurers.
m Ignition keys of the vehicle
m ertificate of insurance and the original insurance policy, if
not stolen with the vehicle.
m Specially worded discharge voucher.

If the vehicle is recovered subsequently the insured will have the

option to repay the claim amount already paid and retain the
recovered vehicle. If the vehicle is found damaged, the insured
will be indemnified against loss of damage.
The procedure for settling third party claims is broadly on the
following lines:
m Intimation of laim: Intimation about an accident resulting into third party
claim is received through various sources:
Insured
laimant
ourts by notice
Through accident report from police in Form 54 prescribed under entral
Motor Vehicle Rules, 1989.

m 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.

m Appointment of Advocate: A competent advocate may be appointed if necessary

to ensure that the proper defence is 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 Oiability amount as per section 140 of the
MV Act, 1989.
Miscellaneous Accident Insurance includes a number of covers, which are
in the nature of package policies. In this situation specific guidelines
applicable to the representative sections are to be followed.

BURGOAR2 INSURAN
The following documents are important while processing burglary
insurance:
m Duly completed claim form
m Final investigation report from the police
m Survey Report
m Photographs

It 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.
The necessary documents for processing workmen's
ompensation claims include:
m Medical ertificate.
m Wages statement.
m Proof of age as recorded by the employer.

For the permanent total disablement claims, the memorandum

of agreement is required to be submitted to the workmen's
compensation commissioner while disposing compensation as per
Workmen's ompensation Act.

For total claims, the perusal of death certificate and postmortem report is
important before depositing the amount with workmen's compensation
commissioner.
The following documents are
required:

m Duly completed claim forms

m Bills, receipts and discharge card
from the hospital
mash memos from the
hospital
mBills from chemists supported
by proper prescription
m Surgeon·s bills and receipts,
bills from pathologist
supported by proper prescription
 m xcept in cases of a marine insurance cover, where current
market practices do not insist on a written proposal form, in all
cases, a proposal for grant of a cover, either for life business or
for general business, must be evidenced by a written document.
It is the duty of an insurer to furnish to the insured free of
charge, within 30 days of the acceptance of a proposal, a copy of
the proposal form.

m Forms and documents used in the grant of cover may, depending

upon the circumstances of each case, be made available in
languages recognized under the onstitution of India.

m In filling the form of proposal, the prospect is to be guided by the

provisions of Section 45 of the Act. Any proposal form seeking
information for grant of life cover may prominently state therein
the requirements of Section 45 of the Act.
m Where a proposal form is not used, the insurer shall
record the information obtained orally or in writing, and
confirm it within a period of 15 days thereof with the
proposer and incorporate the information in its cover note or
policy.

m Wherever the benefit of nomination is available to the

proposer, in terms of 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.

m Proposals shall be processed by the insurer with speed and

efficiency and all decisions thereof shall be communicated by
it in writing within a reasonable period not exceeding 15
days from receipt of proposals by the insurer.
m 6
 

 
 







m 6
  



 







m 6


 


 






 



   







m 6
  
  




 
 
  
 
 
m Sufficient documentary evidence of loss should be
presented along with the application form.

m Multiple claims and reciprocal claims will be settled as

per the terms of the contract of insurance.

m Presence of insurable interest, in case of the property

insurances, at least at the time of happening of event
or loss sufferings. Without having the insurable
interest in the subject matter, no person can get
benefit or compensation.
m The delay in the claims settlement will have an adverse
impact on the goodwill and marketing of the insurance.

m 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.

m The delay in payment may lead to litigation which is

expensive.
-Unproductive use of manpower to defend
-expenses incurred
-waste of time
-will affect on the productive areas of the business
particularly in the marketing of the insurance business.
m Oate submission of claim form along with sufficient proof or
supporting documents
m Innocence and illiteracy of the assured
m Not submitting the claims forms in full
m Oack of motivation or knowledge about the importance of
the claims settlement
m Oack of awareness among the staff of the organizations or
defective supervision
m The delay on the part of the insurer may be intentional or
due to the pressure of work.
m Maintaining confidentiality and neutrality without jeopardizing
the liability of the insurer and claim of the insured;
m xamining, 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;
m onducting spot and final surveys and comment upon excess/under
insurance etc
m Surveying and assessing the loss on behalf of insurer or insured;
m Assessing liability under the contract of insurance;
m Pointing out discrepancy, if any, in the policy wordings;
m Satisfying queries of the insured/insurer and of persons connected
thereto in respect of the claim/loss;
m Giving reasons for repudiation of claim, in case the claim is not
covered by policy terms and conditions;
m Taking expert opinion, wherever required;
m A surveyor or loss assessor shall submit his report to the insurer
within 30 days of his appointment. which can be extended with the
consent of the insured and the insurer.
Insurance underwriting is the process of classification,
rating, and selection of risks.
Thus the underwriter fixes the premium of the product
considering various factors such as cost of risk,
administration expenses, brokerage or marketing
expenditure, claims settlement expenses and budgeted
profit. The premium is the present value of the future risk
sources include:
mThe policy application
mMedical history and examinations
mInspection reports
mThe Medical Information Bureau (MIB)
mThe producer or insurance agent
laims settlement has a direct impact upon
underwriting. If the claims of certain insurance
products are frequently received they have an
impact upon the claims reserves and warrant
review of the product and take decision either to
modify the terms or continue.
Insurance fraud is any deliberate deception/dishonesty
committed against or by an insurance company, insurance
agent, or consumer for unjustified financial gain.

It 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.
reating 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

As such any fraud made by the insured or the insurer in

concluding the insurance contract or the claims settlement,
makes the entire contract voicable 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.
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.
An experienced, competent claims team can·t on it·s
own make your I business profitable«

«WH R AS«

«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)