Guide to efficient Claims Processes In Kenya
WE OFFER PROFESSIONAL INSURANCE CLAIM ADVICE AND FOLLOW UP
Insurance Claim involves the processes of pursuing compensation for an insured loss. Insurance claims can be pursued by the insured or other people affected by the insured’s property or actions; (these other people are referred to as third parties).
General Claim Procedures
- Notification done either by letter, fax, telephone, e-mail, personal visit, company’s website and social media sites
- Immediately Report to nearest police station incase of theft, fire or accident claim. (Get Police Abstract)
- Verbal reporting should be followed by written communication.
- Late notification should be supported
- Claims reported at the branch are registered and forwarded to head office
Upon receipt the claim is then registered within the Insurance Claims system capturing the following information:
• Details of the insured, policy number and period.
• The date of loss and date of notification.
• The nature and location of loss
• The place where the loss occurred.
• Estimated Loss/reserve guided by the Reserving Guidelines
• Acknowledgement contains claim number, service provider appointed and
list of requisite supporting documents
Service providers are as follows;
- Motor assessors – Material damage claims/partial theft
- Investigator – Motor theft and fire damage
- LPO issued to windscreen fitters – Windscreen and glass damage
NON MOTOR CLAIMS
- Loss adjusters – Fire, flood, theft, engineering, BI and other
- Investigators – Bid and complex claims with suspected fraud
- Doctors – Second medical review for injuries
• Assessment for all accidents are done at the insurance company’s assessment center or selected garage.
• Appointment of assessors, submission and review of reports, issuance of Repair Authority, Cash In Lieu and total loss offers are all done by the insurance company.
1. Cash in Lieu
Cash In Lieu is done following the Insured’s request, unavailability of parts or the insured being uncomfortable with the garage allocated by the insurer. The insured is given an upfront amount (often 50% of the repair cost) to commence repairs and balance after reinspection confirming repairs have been completed. NB: Cash In Lieu payments are lower than actual assessors repair estimate since the insurance company reduces 20% of repair cost (markup) and 16% VAT charge.
2. Issuance of Repair Authority
Repair authority is issued to a garage within the insurance company’s panel to commence repairs after approval of assesment report.
3. Constructive Total Loss
Constructive total loss refers to a situation where assessed cost of repairs exceeds 50% of the insured value. The amount paid is equivalent to the vehicle agreed value plus incurred towing fees. Own damage excess is reduced where applicable. What to note following a constructive total loss:
• Vehicle should be towed to authorized salvage storage yards or approved garage for storage
• Total loss offer is issued based on Pre Accident Value (PAV) or Agreed Value as per policy terms
• Offer will indicate Salvage Value should the client wish to retain it
• If not interested in retaining salvage, client will transfer ownership of the vehicle to the insurance company, execute the offer and return it to the insurance company head office alongside security documents for payment processing
• For items left at the garage, client should obtain garage checklist which should accompany the executed offer letter
• Insurance cease immediately following issue of a total loss offer even if the client is retaining salvage
4. LPO’s and reimbursement for windscreen
A Local Purchase Orders can be sent to an approved windscreen replacement service provider to replace your windscreen after approval of yourwindscreen claim. The insured can also replace windscreen and submit claim form, pictures of before and after and copy of ETR receipt for reimbursment of windscreen replacement cost.
5. Reimbursement for repaired vehicles, to agreed limits
The insured might be allowed to repair vehicle upto set limits ad get reimbursed for incurred costs.
Motor Theft and fire Claims
• Claims process is similar to that of total loss
• However, for theft and fire, an investigator or a technical assessor is engaged for fire cases
• Settlement is based on based on sum insured or pre-accident/pre-theft value depending on policy terms
• Theft excess applies for stolen motor vehicles normally at 20% and 10% depending if the vehicle has security features.
• Excess protector does not apply for theft cases unless endorsed in the policy to extend for partial theft
The following categories of claims should be investigated:
• Motor accidents involving injury/death to third parties or passengers.
• All Motor theft and fire claims must be investigated.
• Any claims where the circumstances are not clear or fraud is suspected.
6.1. Review of documents
The documents received are checked for completeness and correctness. A decision is then made on whether the claim is payable or not.
6.1.1. Motor Claims Review
– The assessors report is reviewed. If the vehicle is declared a total loss (usually where the repair cost is more than 50% to 70% of the sum assured), a discharge voucher of the Agreed Value/ the Assessed pre-accident value (PAV) less the excess(Applicable) is prepared for execution by the claimant.
– For Repair cases,
• We can issue a Cash in Lieu Discharge Voucher – 1st CIL DV of 50% or 70% and 50% or 30% issued once repairs are complete and the vehicle is re-inspected.
• Or issue a Repair Authority to a panel garage and once repairs on motor vehicle are complete, release of the vehicle is done after the following conditions are met:
• The claimant pays the policy excess, as per the policy.
• Payment of any outstanding premiums
• A written authority to release the vehicle is given by the company to the garage
• The claimant signs a Satisfaction Note.
– For total loss motor vehicles where the insured is not retaining the salvage, the original log book, signed blank transfer forms, copy of national identity card or certificate of incorporation, the insurance certificate and the car keys must be surrendered to the company before settlement of the claim.
6.1.2. Non Motor Claims Review
• For non- motor claims the loss adjuster’s report is received and checked for reasonableness and if acceptable a discharge voucher is prepared and sent to the claimant (usually through their intermediary) for execution. The discharge voucher will be net of policy excess, which is a percentage of the claim or sum assured depending on the class of business.
– Any salvage must be released to the insurance company before the
claim is settled.
– For Group Persoanl Accident (GPA) and WIBA(Workman Injury Benefit Act) claims the medical certificate is received after the claimant has fully recovered. If the certificate from the attending doctor is not in line with the Continental scale, a second opinion is sought from a doctor on the Insurer’s panel of approved doctors.
• Premium payment must be confirmed before the claim is paid.
- Once a claim has been verified as payable and all relevant claim supporting documents have been received, claims handler shall issue a discharge voucher indicating amount being offered for settlement of claim.
• Issuance of DVs does not apply for motor repair claims, where payment is made to motor repairer.
• A discharge voucher shall be raised upon full documentation and verification.
• A letter giving breakdown of settlement amount shall accompany discharge voucher.
• DV shall be accompanied by a forwarding letter showing computation of offer amount.
• Upon receipt of the duly executed discharge voucher and all claim documentation, the claims handler then raises a payment requisition and the same is duly approved as per the authority limits and forwarded to finance for settlement. A settlement cheque, RTGS or EFT payment shall then be forwarded to the claimant or their intermediary within the set number working days.
Claims may be declined on various grounds, including the following:-
• There is late notification without a valid/acceptable reason
• Premiums have not been paid
• There is proof that claim is fraudulent;(mis-representation of material fact/utmost good faith)
• There has been breach of policy conditions or warranties related to claim in question;
• There was no cover for items being claimed;
• Claim falls outside policy scope of cover
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Motor Claim Support Documents
MOTOR VEHICLE WRITE OFF CLAIMS
– Claim form fully completed, signed and stamped by the insured
– Original logbook
– Confirmation of transfer of Ownership – NITSA
– Copy of the Insured’s PIN certificate
– Copy of the Insured’s certificate of incorporation ( if claimant is a Company) or
– Copy of the ID card ( if claimant is an individual)
– Original and duplicate certificate of insurance
– Original and duplicate vehicle keys
– Front and Rear number plates (if insured is not retaining the salvage)
– Original police abstract report
– Copy of the driver’s valid driving license
– Police vehicle inspection report
– Spare wheel, jack and spanners
– Detailed statement of Insured’s driver & witness statements (if any)
Claim Support Documents
For GPA and WIBA claims, medical certificate shall be received after claimant has fully recovered.
1. Claim form,
2. Medical report/certificate
3. Original medical receipts
4. Sick off sheet(where applicable)
5. 3 months payslips prior to the injury
6. Copy of claimant’s ID
7. Death certificate( if fatal)
1. DOSH forms(1,4 & 7)
2. Claim form
3. Medical report
4. Original medical receipts
5. Sick off sheet(where applicable)
6. 3 months payslips prior to the injury
7. Death certificate (if fatal)
8. Detailed statement( Claimant & supervisor)
9. Police abstract(RTA or Assault)
• If certificate from attending doctor is not in line with continental scale, a second opinion shall be sought from a doctor on the insurance company’s panel of approved doctors.