European Certified Insurance Claims Officer - SQF 5

The country’s legal principles, regulations, directives and code of ethics which may have effect on claims business.

Receive incoming notification of standard claims, generate corresponding records and take first action according to company guidelines

• Receive incoming claims notifications and related information from claimant and through communicating with third parties (customer, underwriter, intermediaries, claimant and others)  for the purpose of obtaining and verifying  claim information
• Check and investigate the coherence, correctness and completeness of information received using the company systems
• When applicable initiate assistance in accordance with the policy coverage

Act in a professional and ethical way.

The policy cover, terms and conditions relevant to your work including standard extensions and/or limitations.

Investigate and Evaluate claims

• Issue, register and process claims related documentation
• Determine the proximate cause of the loss checking whether the proximate cause is one covered, excluded or uninsured by the policy establishing the extent of liability or otherwise
• Assess the damages and the potential exposure to further loss which might aggravate the extent of the claim
• Initiate loss mitigation measures
• Deal with various personnel (such as surveyors, doctors, lawyers, etc.)  to decide whether a claim is valid and to determine the extent of loss
• If necessary, appoint a loss adjuster, to make a report on the cause, validity, extent and necessary recovery works in connection with the claim
• Check whether all policy provisions and conditions have been complied with, including but not restricted to, material facts, morality, general terms and conditions, clauses, exclusions and provisos
• Apply policy provisions, limits and excesses / franchises
• Identify any suspected fraud including money laundering, insider dealing and leakage and report the matter accordingly
• Handle claims economically, efficiently, promptly and fairly in line with the terms and conditions of the policy, the departmental processes, guidelines, practices and standards of the company, the codes of good practice and best ethical practices of the industry and the laws and regulations of the country

Work organized and systematically in order to record details of claims accurately; identify and request missing information and/or documentation.

Methods of claims assessment and investigation and the resources his/her organization has to conduct these activities.

Determine whether to approve in full or in part or decline, liability and/or payment of claims through considering factors under 2 above, within authorised limits

Handle claims economically, efficiently, promptly and fairly.

Methods and prescriptions of loss mitigation, recovery and salvage.

Approve the claim, fully or partly

• Assist and liaise with claims personnel, claimants, suppliers, repairers and other related parties to negotiate cost of claim and recovery
• Register and record the claim and make appropriate claim reserve
• Communicate the decision to the claimant
• Make claim payments to the insured or the relevant beneficiaries in full and final settlement, close and archive the file accordingly
• Handle subrogation, contribution, salvage, litigation and reinsurance within authorised limits
• Forward relevant documentations to the specialist units such as, but not restricted to, the legal units in cases subrogation and recovery
• Decide on admission and/or extent of liability whether in full or in part and forward the claim for payment, otherwise in case of disputed liability or amount  process

Communicates with others in a supervisory position within his/her area of responsibility and authority

The organization’s policies and procedures for processing claims and payment of claims.

Reject the claim, fully or partly

• Forward relevant documentations to the legal units concerned in cases of litigation or fraud
• Communicate the rejection to the claimant
• Close the file in case of absence of objection, in case of fraud or breach of a material fact or after such time when the claim becomes time barred

Establish cause-and-effect relation in order to apply policy provisions, limits and excesses / franchises depending on proximate cause of the claim, indemnity requested, liability and/or negligence if applicable.

Reserving, subrogation, contribution principles.

Communicate effectively with the customer in order to;

• provide information to the claimant or their representative which is clear, accurate and relevant
• show empathy to claimants, using a considered and appropriate language

Create a balance between interests of customer and the organization.

The organization’s customer service standards and procedures, including those for dealing with complaints.

Think critically in order to

• identify the most optimal loss mitigation measures
• distinguish most appropriate application of subrogation and contribution principles, if applicable
• distinguish cases to be managed internally and cases required independent parties like experts.
• detect any possible fraud actions.

Roles & responsibilities of various parties (agents, broker, etc) involved in or influencing the claims handling process

Use induction in order to identify claims which are valid or not valid through combining pieces of information and documentation.

The roles and functions of other parties engaged in claims activities (repairers, surveyors, loss adjusters, doctors,etc.)

Identify own need for continued education and learning.

Authorized experts, suppliers and/or repairers used by your organization to settle claims

Involve relevant parties in the claims settlement process and negotiate the solution

Company guidelines for how to handle suspicions of fraud

Signs of fraud in a claim and the action required.

Communication principles