Claims

Management

REASONS FOR DELAY IN CLAIMS

SETTLEMENT
Late submission of claim form along with sufficient
proof or supporting documents
Innocence and illiteracy of the assured
Not submitting the claims forms in full
Lack of motivation or knowledge about the importance
of the claims settlement
Lack of awareness among the staff of the
organizations or defective supervision
The delay on the part of the insurer may be intentional
or due to the pressure of work.

ROLE OF SURVEYORS AND

LOSS ASSESSORS

 Maintaining confidentiality and neutrality without

jeopardizing the liability of the insurer and claim of the
insured;
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;
Conducting spot and final surveys and comment upon
excess/under insurance etc
Surveying and assessing the loss on behalf of insurer or
insured;
Assessing liability under the contract of insurance;
Pointing out discrepancy, if any, in the policy wordings;
Satisfying queries of the insured/insurer and of persons
connected thereto in respect of the claim/loss;
Giving reasons for repudiation of claim, in case the
claim is not covered by policy terms and conditions;
Taking expert opinion, wherever required;
A surveyor or loss assessor shall submit his report to the

UNDERWRITING

UNDERWRITING IN INSURANCE
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:
The policy application;
Medical history and examinations;
Inspection reports;
The Medical Information Bureau (MIB); and
The producer or insurance agent.

MPACT OF CLAIMS ON UNDERWRITIN

Claims 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.

FRAUDS IN CLAIM
SETTLEMENT

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.

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.

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.

One Final Thought

An experienced, competent claims team cant
on its 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)

THANK YOU
FOR YOUR TIME
AND PATIENCE