European Certified Insurance Claims Handler - SQF 4

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, assisted by company system and guidelines

• 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
• Apply policy provisions, limits and excesses / franchise; company guidelines and practices, and codes of ethics when settling the claim
• Initiate loss mitigation measures according to company guidelines
• If necessary, involve supervisor or others to decide whether a claim is valid, the extent of loss, and how to handle suspected fraud
• Identify if it is necessary to appoint a loss adjuster, and monitor the loss adjusting process and according to company guidelines
• 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

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

General methods of standard 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 pay-ment of claims within authorized limits and within a supervisor authorization

Handle claims economically, efficiently, promptly and fairly.

Basic methods and prescriptions of loss mitigation, recovery and salvage.

Approve the claim, fully or in part

• Assist and liaise with claims personnel, claimants, suppliers, repairers and other related parties
• Register and record the claim internally
• 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 authorized limits and within close supervision authorization
• Forward relevant documentations to the specialist units such as, but not restricted to, the legal units in cases subrogation and recovery
• Forward the claim for payment

Guide peers on how to apply company systems, rules and guidelines when handling standard policies

The organization’s policies and procedures for processing claims and payment of claims, and the authorized limits for your position

Reject the claim, fully or in part

• Communicate the rejection to the claimant
• Forward relevant documentations to the legal units concerned in cases of litigation or fraud, in accordance with company guidelines
• 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.

General principles for reserving and 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

Think responsibly in order to

• indentify the immediate loss mitigation measures
• identify cases, that lie outside of the approved limits and must be forwarded to other units or external experts

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

Maintain a confident relationship with the customer during the claims handling process

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.)

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

Company guidelines for how to handle suspicions of fraud

Understanding of leakage and its effects on insurers

Communication principles