By Amon Rupiya
There is nothing as frustrating as failing to get your claim paid by your insurance policy. This is usually as a result of the submission of inadequate information submitted, errors, policy exclusions, policy exceptions, breach of policy conditions and non-compliance with the policy warranties.
The consequences are catastrophic because the repudiation of the claim happens when you need compensation or indemnity most. Having worked in different insurance markets and experienced claims being repudiated or declined, I have realised that there is little interest in reading about the insurance contracts. Often than not, we hear the foul cry about the small print in the event of claim repudiation.
Allow me to share a few general advices on how to improve your claims success rate. The insurance industry world over faces challenges in claims management which have contributed to the poor image of the industry and low penetration of the insurance services. Most insurance complaints relate to claims process in which the insured participates, suggesting room for improvement in this area of trust between the two parties. Most regulators have been on the insurance companies’ case to improve the relationship with clients as they receive complaints. The industry needs to wriggle out of that deeply rooted mistrust.
The client, who is referred to as the insured or the policyholder in the insurance contract or a beneficiary when the claim is declined, they become financially exposed.
Unfortunately, all insurance contracts are tested at the claims stage, and the claim time can be stressful, but the following will be helpful. It helps to avoid the situation of financial exposure. So read on.
Understand The Insurance Cover From Policy Inception At the moment that you decide to enter into an insurance contract; you have to understand what you are insured for. It is at this initial stage that your insurance broker, agent or consultant should have a conversation for clarity of your cover. Take your time to have the insurance cover be plainly explained to avoid the surprises at the claims stage. Insist on knowing the scope of cover from your broker or agent and the subject matter. Request that they explain to you the defined risk events which are also referred to as the perils. You should know which are the loss events that your policy covers. Have a keen interest in reading what you have signed up for and remember ignorance can never be an excuse in any court of law in the event of a dispute. It takes an average two hours to read and understand the policy document and alternatively you have your insurance broker or agent at your disposal to provide the professional advice. If you are buying the insurance directly, the company has the consultants inhouse to explain the policy cover to you.
Understand What Is Not Covered Most of the insurance policies they have what are called policy exclusions or policy exceptions. These are events or risks that are not covered by the policy and therefore if you know these at the beginning or before you get into the contract. Your insurance adviser should take time to go through all these and sometimes these are generic, and you can possibly request that they are included and depends with the insurance company they may accept such requests at an additional premium. Furthermore, there are what are called policy warranties. A warranty is an undertaking that you make to the insurance company that you will comply with. Any breach of a warranty renders the policy void ab initio From experience, and this has been the major source of disappointment when at the time of your loss, you realise that you were not insured for specific risks.
A typical example is a wear and tear arising of the asset. Many insurance policies do not cover it. No insurance policy covers everything and therefore understand what you are about to purchase to avoid failure at the claims stage.
Reporting The Loss Immediately It is vital to notify your insurance company immediately of the situation where there is a loss, or there is a circumstance that might give rise to a loss. It is a condition in most policies that the loss is reported timeously and within the prescribed time as provided for in the policy. It should be emphasised that the prompt reporting of the loss is essential for preserving evidence that may be critical in determining admissibility and quantum of the claim. If a claim is reported late, it might be prescribed, and that results in a claim being declined. The insurance companies request an explanation for the late notification.
Utmost Good Faith Is the basis of the insurance contract, and it operates even during the claim stage. Disclosure of information to the insurance company during claims processing and increase the right decision and in turn customer satisfaction from a successful claim. Do not get tempted to conceal or exaggerate a claim with the intent to gain more. You will breach the core foundation of insurance’s contract. Report the claim factually and with all the correct details, and you will not have any challenges which might come as a result of misrepresentation of facts or exaggeration which might be interpreted as fraud. Insurance contracts conditions give the right to the insurance company to decline a claim if it is established that you were intentionally trying to conceal or unjustifiably gain from the policy. Truthfulness and accuracy are some of the secret ingredients of a successful Insurance claim, but with the amount of information you need to provide
Completeness and accuracy of information It is imperative that you provide all the required information for the claim to be successful. If you don’t provide all the information that is needed, it could delay your claim being approved, or even worse; it could be declined because you haven’t demonstrated a valid claim exists.
If it is a death claim, the documents may include the death certificate and specific information regarding the circumstance of the cause of death. These documents are further verified by the insurance company to ascertain authenticity. In the medical aid schemes, they will require the prescriptions and the fully completed claim form.
The claim that is not duly and rightfully signed will result in the claim being declined. It is vital for you as the insured to sign off the claim form. The broker or the agent should advise and guide on the document requirements.
Preserve the evidence of the damages The insurance company in the property insurance engages the loss adjustors and assessors to help in determining the cause of loss and amount. The role of the claims adjustor is to determine the quantum and therefore, it is not always that what you put through is what you will receive.
There is a need to allow the company to handle inspection and assessment of damage before settlement. The adjustor has to come up with the fair amount of claim settlement amount that takes into consideration the policy terms and conditions. Now it is imperative that you don’t tamper around with the claim evidence, and this comes in instances where the insured rushes to repair or replace without the concern of the insurance company. This poses a challenge and may lead to the claim being set aside. In life, it is different and substantiating using the documents. Preservation of the documents is therefore paramount, for example, the retrenchment letter in the instance where you are claiming from the employee benefit products.
▀ Amon Rupiya is an experienced insurance practitioner qualified with a Masters in Insurance and Risk Management. He writes in his personal capacity and views does not represent the company he is working for. Please note that the content provided in this article is intended as an overview and as general information only. Before making any decisions based on the information provided in this article, please use your discretion and seek advice from an insurance broker or agent. Feedback and questions send email to email@example.com