Chapter 1 Flashcards
(32 cards)
Why is the claims department known as the ´shop window? ´
It’s where the insurer will be judged
What is the onus of proof?
The insured has to prove they have a valid claim
What 2 things does the insured need to prove to have a valid claim?
- That an insured peril arose
- The amount of the loss
What is the quantum?
The amount of the claim.
Does the insurer also have their own onus of proof?
In a way, yes. It has to prove the peril is covered by the policy and cover was in force etc…
What is the difference between an express and an implied condition?
An express condition is stated in the policy. The implied condition is one that is accepted as applying to the policy but not explicitly stated
What are the 3 breaches of a condition?
- Condition precedent to the contract
- Conditions subsequent to the contract
- Conditions precedent to liability
What happens if a condition precedent to liability is not met?
The insurer may avoid liability for the claim but need not cancel the whole contract
Can insurers refuse to pay a claim if a condition was not met that doesn’t directly relate to the claim at hand
No - unless fraud is involved
What are 3 reasons (conditions) a claim will not fully be met?
- A excess is paid by the insured
- The average clause has been applied (under insurance)
- There is a limit of liability / a set sum insured (and the if the claim is above this they will only pay up until the limit.)
When can an insured challenge a exclusion?
If they were hidden or not transparent
What does «transparency « mean?
Expressed in plain and intelligible English
What does making an exclusion prominent mean?
Brought to the customers attention in such a way that the average person would be aware of it
What is an implied duty and name the most common example.
An implied duty is not found in the policy wording but it’s imposed by common law.
E.g., the insured should act as if they don’t have insurance (and therefore take reasonable precautions)
What are express duties and name the most common examples.
Duties of the insured written into the contract.
- notify the insurer promptly of a claim
- Involve emergency services - if appropriate
- Take reasonable steps to prevent further damage
- Give proof and details of the loss within certain time scales
When do most policies state an insurer should be notified of a claim?
Promptly
What is the FNOL process? Why is it useful?
It’s the first notice of loss process. It’s usually a telephone call to a hotline/claims team or notification via an app.
It can quickly gather details about the claim
What are the main benefits of online FNOL for the insurers?
- Claims are notified quickly
- Insurers have more control over costs
- Less staff are needed
What are the main benefits of online FNOL for the insured?
- Immediate access to the service
- Simple claims process
- No longer waits
- Claims are settled more quickly
- The quality of service is more consistent
What is the main purpose of a claims form?
To establish whether the insured is entitled to indemnity under the policy
Are claims forms specific or generic?
It depends on the type of claim. For example, a motor claim form is going to ask different questions than a property insurance form.
What will an insurer check once a claims form is received?
- The policy is/was in force
- The peril that caused the loss was insured under the policy
Why might insurers check the claims form against the proposal form?
To make sure there was no breach in the duty of fair presentation at the start of the policy
Give examples of supporting evidence in a motor claim.
Images, dash cam footage, satellite images, witness statements, engineering reports
