LIABILITY CLAIMS TRAINING

Transcription

1 LIABILITY CLAIMS TRAINING Presented by: Seonita Avery Manager: Claims Tel: Version

2 DISCUSSION ON LIABILITY CLAIMS HANDLING Part 1 The Policy Part 2 Claims Part 3 Determining merits and quantum Part 4 Claims li=ga=on process Part 5 Claims outcomes se@lement, rejec=on and repudia=on Part 6 Recent claims se@lements Part 7 Rejected / Repudiated Claims Part 8 Claims Trends Part 7 Conclusion / CCTV Footage Version

3 Part 1 The Policy (Proposal, Wording, Schedule) Proposal Form The informa=on provided on the proposal form forms the basis of the cover provided by the Insurer. Policy Wording The policy consists of an Opera8ve Clause, Defini8ons, Condi8ons, Exclusions and Extensions * The Opera=ve clause sets out what Insurers will indemnify the Insured against i.e. their legal liability to pay compensa=on for and / or arising out of Injury and / or Damage. The cover excludes USA and Canadian claims. * Condi=ons set out the Insured s and the Insurers du=es and responsibili=es * Exclusions set out what is not covered in terms of the policy * Extensions are the op=onal extras added to the policy and are reflected on the policy schedule Policy Schedule Is a summary of the cover, it sets out the period of insurance, retroac=ve date, policy limits, deduc=ble/s and extensions. When a claim is made against the Insured, the circumstances surrounding the claim must be within the ambit of the policy. Version

4 Part 2 Claims No8fica8on of Claims A claim may be defined as a legal demand for payment due to loss / injury / damage allegedly caused by the negligence of the Insured party. To do list when a claim is no=fied: 1. Check whether a valid policy is in force i.e. is the claim made a`er the retroac=ve date and within the policy period, is the premium paid? 2. Does the policy cover the loss claimed for; 3. Was the claim no=fied =meously; 4. Have the policy condi=ons been adhered to. Once cover has been confirmed and depending on the complexity of the ma@er the Insurer has the op=on of dealing with the inves=ga=on / assessment of the claim inhouse or appoin=ng a loss adjuster. The claims inves=ga=on / assessment period varies depending on the complexity of the ma@er and the co opera=on of the broker and Insured. Li=gated ma@ers are dealt with by duly qualified and experienced a@orneys appointed by Insurers. The finalisa=on of these ma@ers are not determined by Insurers and is en=rely dependant on the Courts.

5 Part 3 Merits and Quantum Merits The merits of a claim are the details surrounding the claim i.e. What, When and How? Merits inves=ga=ons involve the gathering of informa=on and forming a view on whether the Insured is in fact legally liable to pay compensa=on to a third party due to the Insured s negligence. At this point Broker co opera=on is vital informa=on requests are sent to the broker who must obtain same from the Insured. The informa=on requested depends on the type of claim but generally includes amongst other things: summary segng out details surrounding the claim witness statements CCTV footage all correspondence between the Insured and Third Party This process is controlled by the Broker who controls the flow of informa=on between the Insured and Insurer. Version

6 Part 3 Merits and Quantum continued.. Quantum The quantum of a claim is the monetary value i.e. the damages in Rands of the injury /loss / damage allegedly sustained by the Third Party. This amount is usually overstated and not a true reflec=on of the value of the claim. Quantum determina=on only begins when the merits of a claim have been determined and it is established that a valid claim has been made in terms of the policy. The determina=on of the quantum varies depending on the type of claim. A medical malprac=ce claim requires various experts to compile reports and debate the injuries and sequelae thereof. These quantum determina=ons may take months and in some cases years. In most cases this is ul=mately determined by a Court of Law. With other classes of Insurance, quantum may be determined by nego=a=on, quote comparison and case law. The key to se@ling quantum is being fair and reasonable in respect of the offers of se@lement made. Version

7 Part 4- Claims Litigation Process LeFer of Demand A le@er of demand is the 1 st step in the claims process and sets out the Who, What, Where, When and Why of the claim. It must usually be responded to within a period of 14 days, this does however vary depending on the writer. NB A QUOTE IS NOT A LETTER OF DEMAND Summons A Summons is the 1 st step in the li=ga=on process. It is issued by the Court at the request of an A@orney and formally served on the Insured by the Sheriff of the Court. It sets out the allega=ons made in the le@er of demand and damages more comprehensively, the Insured has 10 days to enter an appearance to defend. Judgement In the case of li=gated ma@ers if no agreement is reached between the par=es in respect of se@lement of claims, the Magistrate / Judge makes a ruling in respect of the issues in dispute based on the representa=ons made by the li=ga=ng par=es. Should either party disagree with the Judgement made, an Appeal may be lodged. This can be a long drawn out expensive process. Version

8 Part 5 Claims Outcomes Settlement, Rejection and Repudiation Claims seflements Claims se@lements are achieved when the par=es come to an agreement as to the merits and quantum of a claim. When a claim is se@led a Tender of Se@lement is signed by the Insured. Rejec8ons A claim is rejected when the Third Party fails to prove his claim. Should a Summons follow the rejec=on, Insurers will defend the Insured in such proceedings. Repudia8on A claim is repudiated when the Insured fails to comply with his policy condi=ons. A claim may be repudiated due to: non disclosure misrepresenta=on non payment of premium event giving rise to the claim occurred prior to the retroac=ve date or incep=on of the policy there is in no cover in place for the event giving rise to the claim Version

9 Part 6 Recent Claims Settlements Medmal claims settlements Cerebral palsy R20 Million Loss of support death - due to incorrect diagnoses R General liability claims Injury due to slipping and falling in a mall injured hip and ankle R Burn wounds caused by the tipping over of an urn R Pension Fund Trustee Claims Misappropriation of funds by a trustee R46 Million Fraud by administrator staff R Commercial Crime Fraud committed by employee in collusion with others R Hi jacked vehicle - goods stolen before delivery takes place, staff involvement R

10 Part 7 Examples of Rejected / Repudiated Claims - Trolley used as child transport - Vehicle driving through the exits without waiting for the spikes to go down - Incorrect fuel when the third party stops at the incorrect pump deliberately - Administrator negligence in respect of Pension Fund claims - Fraud / theft by security officers in collusion with others - Eating last nights dinner (take away chicken) and choking on a chicken bone

11 Part 8 Claims Trends Misfuelling : Increased quantum Auto body repair / tyre claims increase. Spread of fire claims KPMG report 25 30% of all Short Term Liability claims submi@ed in 2013 were fraudulent claims, cos=ng the Industry approx. R400 million Slip and Trip Subrogated claims dying out Unwillingness to claim against other / own policies e.g. contractors Brokers / Client rela=onship (managing expecta=ons)

12 Part 9 - Conclusion / CCTV Footage / Questions