Page 434 - IC38 GENERAL INSURANCE

b) Claims assessment

In case of fire, claim is assessed on the basis of a police report, investigators
report if cause is unknown and a survey report. For personal accident
claims, the insured is required to submit a report from the attending doctor
specifying the cause of accident or the nature of illness as the case may be,
and the duration of disablement.

Under policy conditions, the insurers reserve the right to arrange an
independent medical examination. Medical evidence is also required in
support of “Workmen‟s Compensation” claims. Livestock and cattle claims
are assessed on the basis of the report of a veterinary doctor.

Information

On receipt of intimation of loss or damage insurers check whether:

1. The insurance policy is in force on the date of occurrence of the loss or
damage

2. The loss or damage is caused by an insured peril
3. The property (subject matter of insurance) affected by the loss is the same

as insured under the policy
4. Notice of loss has been received without delay.

Motor third party claims involving death and personal injuries are assessed on
the basis of doctor‟s report. These claims are dealt by Motor Accident Claims
Tribunal and the amount to be paid is decided by factors like the age and
income of the claimant.

Claims involving third party property damage are assessed on the basis of a
survey report.

 Motor own damage claim is assessed on the basis of surveyors report.
 It may require police report if third party damage is involved.

Information

Investigation is different from the assessment of loss. Investigation is done to
ensure that a valid claim has been made and verify the important details and
doubts like absence of insurable interest, suppression or misrepresentation of
material facts, deliberately creating the loss, etc. are ruled out.

Health insurance claims are assessed either in house or by third party
administrators (TPA‟s) on behalf of the non-life insurance companies. The
assessment is based on the medical reports and expert opinion.

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