Page 38 - Claims Binders Mandates and Guidelines

1.8 Proceed with authorisation of the claim only if the claim does not form part of the criterion as mentioned in point 1.3 of this section, for example, exceeding your claims mandate.
1.8.1 Proceed according to the loss adjuster’s report, provided that there is a valid loss in terms of the policy, the claimant is not under insured, and premium has been paid on time.
1.8.2 Where there is underinsurance, the loss adjuster calculates the average and then provides us with their settlement recommendation. The claim may then be settled on a cash-in-lieu settlement basis should the underinsurance be more than the allowed 10% (ten percent). No authorisation can be given for replacement of items where there is underinsurance and average applies.
1.9 Appoint a Hollard Insure approved contractor to do the repairs:
1.9.1 per the assessment report; provided that the claimant is not under insured.
1.9.2 however, where there is underinsurance, the assessor has to provide us with full details of value at risk and average calculations before we obtain the signed agreement of loss and settle cash- in-lieu. No authorisation can be given for repairs where the claimant is under insured and where average is applicable.
1.10 Where you have provided authorisation for replacement of any items, diarise your file and follow up on invoices. Once the invoice is received, proceed with payment once you have:
1.10.1 received a signed release or delivery note from the claimant, and
1.10.2 received the original VAT invoice, not an emailed document.
1.11 Ensure that you compare the invoice amount to the amount that you have authorised or that has been agreed by the loss adjuster. If the amount of the invoice does not match the authorised amount, investigate and question any additional amount that may not have been agreed upon.
1.12 Where the claim may be considered as a possible rejection:
1.12.1 prepare the file together with all the claims documentation, and forward copies to Hollard Insure.
1.12.2 based on the merit of the matter and considering the policy wording Hollard Insure may decide on proceeding with a rejection by drawing up a rejection letter. Rejection letters need to be sent to the claimant and same to be recorded on the binder holder’s file.
1.12.3 any possible rejection must be properly communicated and explained to the claimant.
1.12.4 the claims decision from Hollard Insure will always adhere to Hollard Insure’s claims policy and philosophy.
2. GUIDELINES FOR APPOINTING LOSS ADJUSTERS
It is important to remember that the claims department of an insurance company is the showcase of the company, and whilst the loss adjuster is independent, in the public eye he represents the company.
2.1
Common benefits and reasons for appointing loss adjusters
2.1.1 Indication of moral hazard
2.1.2 Report on physical hazard
2.1.3 Checking adequacy of sum claimant
2.1.4 Insurance history
2.1.5 Handling the complexity of a claim and adjusting the claim accordingly
2.1.6 Referral to specialists for repairs and replacement and adjust the claim accordingly.
Where there is doubt regarding circumstances and quantum and/or fraud is suspected, thorough investigation is to be undertaken.
If fraud is raised as an indicator by the loss adjuster, contact should be made with our LVD by email on investigations@hollard.co.za for purposes of notification. The loss verification division will provide guidance and oversight in terms of the handling of the investigation.
Non-motor Claims Procedures
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Claims Binder Holders Mandates and Guidelines – V6: 2022