Claim Mgmt Process

Life Insurance Claims

 Essential

Elements of Insurance  Concept of Claim  Beneficiaries under Life Insurance claims  Claims Payment on Maturity  Claims payment on Death  Disputes in Life Insurance Claims  Settlements of Claims  Limitation of claims

 Concept

of Insurable Interest

 Doctrine

of Good Faith

 Proximate

Cause

Claim is a right of insured to receive the amount secured under the policy of insurance contract promised by Insurer.

Beneficiary depends on the following conditions: Nomination  Transfer  Assignment



The amount insured or face value of policy



Bonus if declared by company



Share of profit in case of participation policy



Surrender value if policy lapsed

Procedure of Claim Settlement 

Letter of intimation of Death including

4.

Proof of Age

6.

Death certificate

8.

Policy number and name

10.

Name & address of claimant



3. 4. 5. 6. 7. 8. 9. 10. 11.

Internal enquiry when notice received Any dues pending Policy status lapsed or running Exclusions & inclusions of that policy Nomination, assignment or transfer Cause of death Place of death Hospitalization details (if any) Statement of Doctor & hospital Statement from organization where the person is working

For unnatural death accidents or suicide etc FIR post mortem chemical analysis report

 2. 3. 4.

 If

original death certificate not available, then alternative proofs considered such as-

8.

Death in air crash

10.

Disappearance on board a ship

12.

Presumption of Death if not seen for seven years

Procedure for Claim settlement Policy document submission 4. Age Proof 5. Internal enquiry 6. Original Deed of assignment (if any) 7. Other documents (Receipt of Payment etc) 3.

 Identify

made

the person to whom the payment is to be

 Whether

the payment is within the terms of policy

 Whether

the amount claimed is reasonable

 Proof

of Death

 Identification

of assignee, nominee or the legal heir to whom the payment is to be made

 Settlement

within sixty days if no Dispute

 In

case of dispute, company can apply to court within ninety days on following circumstances:

  

When there is conflicting claimants When there is insufficiency of proof When there is any other adequate reason

Limitation of claim Claim

concessions

Administrative Ex-Gratia

concessions

Case study  Kantiben

took life insurance policy on 2-3-97 for two lakh & paid premium regularly  In 1999 she was diagnosed as suffering from cancer  Continued to pay premium without any notice to LIC & She expired in 2 feb 2000  Nominee approached to LIC for claim  LIC refused to pay on the basis of fraudulent to not report her health status when she was required to do so.  Nominee approached to State commission for justice

Case study  Dharam

took policy on 3-7-96 with FIL for 5 lakh & submitted his medical report  After two year he diagnosed Rheumatic Heart disease & died on 11-9-99  His wife claimed for payment  FIL repudiated the claim on context of hiding information about disease  His wife then approached to state commission for justice What do you think should she get sum assured or surrender value or nothing.