Claims 理賠

Purpose and Importance of the Claims Function 理賠功能的目的及重要性

Claims handling is the point at which the insurer delivers on its promise. After a loss, the insurer must pay valid claims promptly, fairly and in the correct amount, and decline claims that are not covered or are fraudulent. Paying too little harms customers and the insurer's reputation. Paying too much, or paying invalid claims, is unfair to the other policyholders, because claims are paid from the common pool made up of everyone's premiums.

Claims experience also feeds back into the rest of the business. Claims data helps underwriters and actuaries judge whether premium rates are adequate. It shows product development where policy wording is unclear, and it is the basis for setting claims reserves. For many customers, the way their claim is handled is what they remember most about the insurer.

The Claims Procedure 理賠程序

A claim starts when the insured notifies the insurer. Policy conditions usually require notice as soon as reasonably possible, sometimes within a stated period. They may also impose other duties: theft must be reported to the police; reasonable steps must be taken to stop the loss getting worse; and in liability insurance, the insured must not admit liability to the third party or offer a settlement without the insurer's consent. Depending on the policy wording, breach of these conditions may entitle the insurer to reject or reduce the claim.

The insurer then asks for a claim form and supporting evidence, such as invoices, repair quotations, or police or medical reports. A death claim under a life policy normally needs three things. First, proof of death (the death certificate). Second, proof of age, if age was not admitted at inception. Third, proof of title, which shows who is entitled to the money: a named beneficiary, an assignee, or the deceased's personal representatives holding a grant of probate or letters of administration. A maturity claim is paid to the policy owner when the policy and a signed discharge are returned.

Before paying, claims staff check five things. Was the policy in force when the loss happened? Was the loss proximately caused by an insured peril, and is it outside the exclusions? Did the insured comply with the policy conditions? Does the claimant have an insurable interest (for property, at the time of loss)? Does the amount claimed reflect the real loss, after deducting any excess and applying average or contribution with other insurers where relevant?

On the burden of proof, the insured must prove that a loss occurred and that an insured peril caused it. If the insurer refuses the claim because of an exclusion, the insurer must prove that the exclusion applies. Once it has paid an indemnity, the insurer may use its subrogation rights against a responsible third party, and it is entitled to any salvage.

Loss Adjusters and Loss Assessors 損失理算師與損失評估師

A loss adjuster is an independent specialist appointed and paid by the insurer, usually for large, complex or technical claims. The adjuster investigates the cause and circumstances of the loss, checks whether it is covered, assesses the amount and negotiates a settlement with the claimant. Although the insurer pays the fee, an adjuster is expected to act impartially and apply the policy terms fairly. The adjuster only advises; the final decision to pay rests with the insurer.

A loss assessor is appointed and paid by the insured to prepare and present the claim and to negotiate with the insurer on the insured's behalf. The insured normally bears the assessor's fee, which is usually not covered by the policy. Exam questions often test whom each one acts for: the adjuster is appointed by the insurer, and the assessor acts for the insured.

Settlement Methods, Ex Gratia Payments, Fraud, Reserves and Disputes 賠償方式、通融賠付、欺詐、準備金及爭議

Property claims can be settled by cash payment (the most common method), by repair (common in motor claims), by replacement (for example glass or jewellery) or by reinstatement, where the insurer restores a building to its condition before the loss. The policy usually gives the choice of method to the insurer, not the insured. Once an insurer elects to reinstate, it must complete the work even if the cost turns out higher than expected.

An ex gratia payment is a payment an insurer makes as a goodwill gesture when it has no legal liability under the policy. For example, it might pay part of a loss to a long-standing customer whose claim fails on a technicality. An ex gratia payment does not admit liability and does not set a precedent the insurer must follow in future.

A fraudulent claim, such as an invented loss or a deliberately inflated amount, may be rejected in full, and the claimant may face criminal prosecution. Claims staff watch for warning signs to protect the interests of honest policyholders.

Claims that have been reported but not yet settled are covered by an outstanding claims reserve. Claims for losses that have already happened but have not yet been reported to the insurer are covered by an IBNR (incurred but not reported) reserve. A claimant under a personal policy who disagrees with the insurer's decision can complain to the insurer first and then to the Insurance Complaints Bureau. The Bureau's rulings bind the member insurer but not the claimant, who can still take legal action.