European Certified Insurance Claims Manager - SQF 6

The details of the country’s legal principles, regulations, directives and code of ethics which affects claims business.

Receive incoming complex claims notifications, generate corresponding claims records and take first action

• 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
• When applicable initiate assistance in accordance with the policy coverage

Ensure that the claims handling process is handled in a professional and ethical way.

In detail, the company’s policy cover, terms and conditions, including extensions and/or limitations.

Investigate and evaluate complex 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
• Use knowledge of the insurance class to investigate and assess the damages and the potential exposure to further loss which might aggravate the extent of the claim
• Initiate loss mitigation measures
• If necessary, involve 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 take action 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

Handle claims economically, efficiently, promptly and fairly.

The policy cover, terms and conditions of the company’s main competitors.

Approve the claim, fully or partly

• Negotiate cost of claim and recovery with claims personnel, claimants, suppliers, repairers and other related parties
• Register and record the claim internally and make appropriate claims reserves
• 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
• If necessary involve specialist units such as, but not restricted to, the legal units in cases of 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

Apply specialized knowledge to determine validity of the claim.

The specifics of methods of claims assessment and investigation, in theory and in practice.

Reject the claim, fully or partly

• Involved the relevant units 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

Involve relevant (internal and external) parties in the claims settlement process and negotiate the solution

The specific insurance challenges related to the given insurance line

Evaluate the customers current and past claims and decide whether to change or terminate the customer’s policy and coverage

Supervise and spar with employees and other departments during the claims handling process and approve final settlement

In detail, methods and prescriptions of loss mitigation, recovery and salvage.

Communicate effectively in order to;

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

Analyse the claim 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.

Methods for applying reserving, subrogation, and contribution.

Set, monitor and maintain company guidelines and processes

• Ensure a quick and efficient settlement of claims as well as decision-making in cases of larger claims within the framework of defined competences
• Optimise Process Management

Ensure that claims are settled in a way that benefit both the customer and the company, through

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

In detail, the organization’s policies and procedures for processing claims and payment of claims

Ensure compliance and upkeep with market developments

• Keep abreast of market trends and tendencies
• Collect data and market information (outsource or in-house)
• Ensure the investigation of client-specific and/or product-specific claims developments

Ensure and manage an effective collaboration and communication with relevant units such as legal, underwriting, sales and marketing,

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

Monitor claims performance and take corresponding decisions

• Identify noticeable claim trends in cooperation with other the departments in order to optimise performance such as, but not restricted to, claims ratio
• Monitor claims outstanding, IBNR, reserves, expenses, recoveries and claims paid to ensure optimal results

Build and maintain a profitable customer relationship

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

Manage key information related to claims handling

• Advise customers, employees and direct sales force on all claim matter
• Inform departmental employees in a timely manner on all technical, operational or organisational changes. Supervise the orderly implementation and enforcement of working guidelines and processes

Continuously improve the claims handling processes and guidelines

The roles and functions of other parties engaged in claims activities (experts, suppliers, repairers, surveyors, loss adjusters, etc.), including those used by the organization to settle claims

Co-operate/liaise with legal representatives on legal matters

• If necessary, initiate dispute resolution channels like arbitration and mediation proceedings and represent the company on all legal matters

Ensure that the organizations (inside and outside ‘Claims’) are updated on claims handling products, tools and processes

Methods of identifying suspected fraud in a claim and the action required.

Communication principles