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IF 2 > CH 11 CLAIMS > Flashcards

CH 11 CLAIMS Flashcards

1
Q

It’s whose responsibility to prove that the claim is valid

A

It’s the insured

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2
Q

What do insureds provide to prove validity of a claim

A
  • That an insured peril arose

- The amount of the loss

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3
Q

To show that an insured peril arose, what must they prove

A

An insured must prove that they have suffered a loss directly caused by the insured peril

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4
Q

In which form can you find the proof of loss, filled by the insured

A

The form of a completed claim form

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5
Q

To show the amount of the loss what must they prove

A

Where the policy is of indemnity, insured must prove that they have suffered a financial loss and identify the amount of the loss suffered

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6
Q

The proof from the insured of the financial loss suffered might take the form of

A
  • purchase receipt
  • a repair amount
  • a valuation
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7
Q

When does the onus of proof of loss rest with the insurer

A

If the insurer wishes to decline to pay a claim because of the operation of an exclusion in the policy terms. Thus onus is upon the insurer to prove that the exclusion applies

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8
Q

During a claim validity process, what is the responsibility of the insurer

A
  • to ensure that the cover is in force at the time of the loss
  • the insured is that named in the policy/person to be indemnified
  • the peril/event is covered by the policy
  • insured has taken reasonable steps to minimize the loss
  • conditions and warranties are complied with
  • duty of fair presentation hasn’t been breached
  • no exceptions are appropriate
  • the value of the loss is reasonable
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9
Q

There are situations in which claim is valid,but is partially met. This would a result of

A
  • Insured’s choice as in the case of first loss policy
  • An imposed policy term i.e. compulsory excess
  • Poor insurance arrangments
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10
Q

How do Sum insured/limit of liability lead to claim being partially met

A

This occurs if the measurement of indemnity following a loss is greater than the sum.limit, thus insured’s recovery is limited to this sum/limit

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11
Q

How does the operation of the average clause lead to claim being partially met

A

In the case of under insurance of property insurance, the insurer may apply average to any claim put forward, and pay a proportion of the insured’s loss

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12
Q

What is Ex gratia

A

These are payments made by the insurer “out of favour”, it acquires no subrogation rights as they only flow from an indemnity payment

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13
Q

Duties of the insured after a loss are divided into two which are

A

Implied duties and Express Duties

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14
Q

What are some of the implied duties of the insured after a loss

A

These are not necessarily found in the policy wording but are imposed at common law

  • insured should act as though uninsured,and take reasonable steps to minimize the loss
  • may be required to advice appropriate authorities in the event of loss
  • must take all steps to prevent loss from spreading
  • must not hinder insurer in the claim investigation process
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15
Q

What are express duties

A

They are written into contract and are usually found as claim conditions in the policy.

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16
Q

A breach of express duties/claim conditions lead to

A

The insurer to repudiate the particular claim

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17
Q

What is claim procedure or action by the insured

A

This is also known as the Notification condition, which is a condition that sets out duties of the insured on happening of the event insured against

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18
Q

So basically express duties will require the insured to

A
  • prompt notification to the insurer
  • involvement of the police
  • reasonable prevention of further damage
  • proof and detail of loss in writing with a certain time scale
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19
Q

When is a claim form issued

A

Once insurer is advised of a claim by the insured,then the insurer will issue it

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20
Q

What are the purposes of a claim form

A
  • establish whether the insured is entitled to indemnity under the policy
  • provide enough information to allow insurer to process the claim
  • enable insurer to take a view as to the severity interms of the potential cost of the claim
  • enable insurers to take preliminary view on whether there is likely to be a claim from third party
  • enable the insurer to consider whether any potential recovery rights may exist
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21
Q

How can the claim forms be completed

A

They can be completed online, with help of special mobile apps and can be completed manually by printing them

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22
Q

How are sufficient information on claim collected by motor and household insurance

A

They can be collected over the phone-through the use of a freephone helpline or claim line facility

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23
Q

Claim form in Motor insurance is known as

A

Accident Report Form

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24
Q

Why is it known as an Accident Report Form, rather than Claim form

A

In motor insurance it is a policy condition that all accidents are to be reported to the insurer irrespective of whether or not insured intend to make a claim

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25
Q

What are the advantages of using specialized claim apps for the insured

A
  • to make a claim using a helpful step by step guide found in the app
  • having all the insurance phone numbers required to hand
  • by allowing them to save the claim for later/send it straight to the insurer
  • allowing them to send any claim document, insurer has requested
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26
Q

For Motor accident, the claims app assist the insurer by

A
  • use GPS to show the insurer exactly where the accident occurred
  • upload photos of any damage to the vehicle and where it occurred
  • take down address and name of anyone who saw it happen
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27
Q

For household claim, the claims app assist the insurer by

A
  • stores copies of receipt’s and warranties safe for the insured’s in one place
  • the insured can make use of their phone’s camera to show damage to their home and belongings
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28
Q

On the receipt of the completed claim forms what must the insurer do next

A

They must check the form against the policy records and underwriting department to ensure policy is in force and the peril is covered. They must also check the answers in the claim form with those in the proposal form in order to ensure no breach of duty of fair presentation

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29
Q

After checking the claim for and being satisfied with the results, what’s the next move

A

They must ensure that the value loss is reasonable

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30
Q

How does the insurer ensure that the value loss is correct

A

This is achieved by number of means

  • including the experience of the claim staff
  • looking at catalogs
  • price list
  • reference books
  • referring to the experts in the insurance field
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31
Q

How are small domestic claims dealt with

A

They are dealt with quite rapidly by in house claims staff, if the claim form is correctly filled in and all is in order

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32
Q

How are Larger and complicated claims dealt with

A

A claim officials might visit the claimant to inspect the damage and for complicated claims a loss adjuster is generally used

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33
Q

What are some of the supporting evidence needed for Motor claims

A

A vehicle registration document in the event of a total loss

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34
Q

What are some of the supporting evidence needed for Accident claims

A

In a factory accident, it’s desirable to obtain engineer’s report, including scale plans and photographs

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35
Q

What are some of the supporting evidence needed for personal injury and sickness claims

A

Medical evidence/ doctor’s certificate is essential

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36
Q

What are some of the supporting evidence needed for theft claims

A

Compare details of the property stolen as given to the claim form with the list given by the insured to the police

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37
Q

Who are Loss adjusters

A

They are independent and professionally qualified to handle complex claims/investigation/negotiations and settlement process. They act on the behalf of the insurer, thus fees paid by them

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38
Q

How do loss adjuster process claims

A

They process claim from start to finish

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39
Q

How do loss adjuster ensure that insurers interest is preserved

A

They do this by checking that the cover is in force and was adequate at the time of the loss

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40
Q

Who is a loss assessor

A

This is a person/firm that is employed as an expert by the insured to assist in the preparation of the cost. Fees are covered by the insured

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41
Q

What is contribution

A

Only applies to policies of indemnity, this is the right of an insurer to call on other insurers similarly but not necessary equally, liable to the same insured to share the loss of an indemnity payment

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42
Q

How is the principle of contribution modified

A

It is modified by the contribution condition found in all non-marine policies, limiting insurers liability to their related proportion of the loss,whilst other policies exist

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43
Q

How do insurers know that the insured has other insurances in force

A

There is always a question specifically relating to the existence of other polices on insurers claim forms

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44
Q

A typical basic formula for contribution is

A

sum insured by individual insurer/total sum insured * loss

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45
Q

When does the average condition apply

A

Notably in property insurance, if the sum insured is not enough to cover the full value of the risk insured i.e. under insurance

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46
Q

In averaging what does the insurer pay

A

The insurer pays a proportion of the loss based on the relationship between the sum insured and the full value of the risk insured

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47
Q

What is the average formular

A

Sum Inusred/Value at risk *Loss

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48
Q

Can averaging be applied to liability and money policies

A

No t because the insured has simply chosen a limit of indemnity. This is can be applied to property and business interruption insurance that have sum insured

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49
Q

Under common law when can an insurer takeover the subrogation rights

A

Until the insured has been fully indemnified under the policy

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50
Q

When can an insured acquire subrogation rights

A

under the terms of a statute or contract that has been entered

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51
Q

When can an insurer exercise subrogation rights

A

Insurers can immediately pursue their rights and doesn’t have to wait until the claim has been settled

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52
Q

Insurers are entitled to begin pursuing recovery rights before a claim payment under the subrogation condition, however when are they entitled to receive the payment

A

They are not entitled to to obtain the amount of the recovery until they have actually paid the insured’s claim

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53
Q

What is an arbitration clause

A

This clause deals with disputes which arise as to the amount to be paid in a claim settlement under a policy

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54
Q

What is arbitration clause not similar to

A

It is not similar to the disputes as to whether or not liability exist

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55
Q

When there is a dispute of the amount of claim to be paid who is appointed

A

An arbitrator is appointed by the two parties in accordance with the current statutory provisions

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56
Q

What are the benefits of using Alternative Dispute Resolution (ADR)

A
  • Speed of completion
  • it can be timed to suit the parties
  • it is less costly than proceeding through the court trial
  • settlements are confidential between the parties, there is no public record
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57
Q

The two principle forms of ADR, less formal than arbitration are

A
  • Mediation

- Conciliation

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58
Q

Decision made by the arbitrator is

A

The decision is usually binding between both parties

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59
Q

What does the Civil Procedure Rules(CPR)

A

Courts have a duty to encourage parties to use Alternative Dispute Resolution procedure and to facilitate the use of it where the court deems it appropriate

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60
Q

What is Mediation

A

This is a dispute resolution process, where by the parties choose to participate and any agreement reached to settle is made solely by the parties, the mediator act as a facilitator and is selected by the parties but makes no decisions

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61
Q

What is the mediators job in mediation

A

They help the parties understand the dispute and in particular ensure that each party fully understands the other’s position, thus helping them reach a dispute settlement agreement

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62
Q

What us Conciliation

A

Similar to mediation but the conciliator’s role is to lead the parties into a settlement

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63
Q

For Conciliation as an ADR, what do the parties have to agree with prior to using it

A

The have to agree that they will be bound by the conciliator’s recommendations, thus they will not usually have any recourse for a more formal court system later

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64
Q

If a matter is bought to the court, what can they chose to do

A

They can refer matters before them to ADR processes,if they feel it is appropriate

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65
Q

What are the advantages of ABI personal effects contribution agreement

A
  • it avoids adverse publicity and criticism of the insurance industry caused by insurers referring policyholders to other insurers for payment of part or all the claim
  • avoid costly and time consuming handling and small contribution payment amount
  • sets rules of contribution between the participating insurers
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66
Q

The ABI personal effects contribution agreement

A

Deals with claim for the loss of personal effects covered by two or mote policies.

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67
Q

What do the ABI personal effect contribution agreement, rule on Motor accident/thefts

A

There shall be no contribution request from other insurers, claims of personal effects lost/damaged in motor accidents/stolen from vehicles will be settled by the insurer whom the claim is made to subject to the policy limit

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68
Q

What do the ABI personal effect contribution agreement, rule on specified items

A

Generally there is no contribution, insurer of the specified item will meet the claim unless the item is specified under another policy, then they can settle the claim and recover a contribution from the other insurer

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69
Q

What do the ABI personal effect contribution agreement, rule on All other circumstances

A

Contribution is required. Insurer by whom the claim is made against will settle the claim, they may recover a contribution from other liable insurers if the amount exceeds 200 pounds

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70
Q

In non-motor policies,The no claim discount provision will not be prejudiced

A

If a payment is made to another insurer in reimbursement under the terms of agreement

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71
Q

What are Bi lateral Agreements

A

These are agreements made by insurers operating in the same market, engaging with similar like minded insurers, making it easy to communicate with each other on claims involving subrogation and contribution

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72
Q

The Motor Insurers Bureau is agreement between who

A

The Government and Motor Insurers

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73
Q

How does the Motor Insurers Bureau operate

A

It operates as a central fund to provide compensation for injury/damage following a motor accident where it can’t be obtained from another source

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74
Q

Which liabilities is the Motor Insurers Bureau concerned with

A

The Road Traffic Act Liabilities

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75
Q

How does the Motor Insurers Bureau maintain its funds

A

By a levy on member companies

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76
Q

The Motor Insurers Bureau operates under two agreements

A
  • untraced drivers agreement

- uninsured drivers agreement

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77
Q

Why does the uninsured driver agreement exist

A

In situations where an uninsured driver cause injury/damage in an accident, thus leaving no insurance in place to provide compensation to the third party, then it will step in to settle or ensure settlement of unsatisfied court judgement were damages are awarded to third parties personal injury or damage to property

78
Q

When do MIB members agree to pay for uninsured drivers damage

A

Where an unsatisfied judgment is against an individual who had a policy in force with that member at the time of the accident but which owing to a breach of its terms, doesn’t indemnify the motorist involved

79
Q

For MIB payment to third parties damage to property and injury claims are there any excesses

A

No excess does not apply

80
Q

How do some comprehensive policies offer extra protection from being hit by uninsured drivers

A
  • by waiving excess

- by protecting insured’s no claim bonus when they are hit by uninsured drivers

81
Q

What information is an insured supposed to provide when hit by an uninsured driver

A
  • vehicle registration number
  • Make and model of the vehicle
  • Drivers contact details
  • if possible name and addresses of the witnesses to confirm assault
82
Q

If the insured has a third party. third party fire and theft and gets into an accident caused by uninsured driver then

A

The insured is unable to claim in their own insurance and have to rely on the MIB procedure

83
Q

If third party insured causes an accident with uninsured party then

A

The insured will be responsible for repair costs to their vehicle and the uninsured vehicle(covered by the insureds third party insurance)

84
Q

Untraced Drivers agreement deals with

A

It covers hit and run,where the motorist involved in the accident can’t be traced

85
Q

untraced drivers agreement covers

A

It covers both death and personal injury

86
Q

The MIB will make payments for untraced drivers agreement when

A

The untraced motorist would be liable to pay damages tot he accident victim in respect of death or injury

87
Q

What is the limit for third party property damages of MIB

A

1.2 million pounds and unlimited for third party death or injury

88
Q

According to the MIB significant personal injury relates to

A
  • one that results to death
  • one for which 4 or more days of consecutive in patient treatment in a hospital, the treatment starting within 30 days of the accident
89
Q

MIB untraced driver agreement compensation is subject to what excess

A

Minimum of 300 pounds

90
Q

For compensations done by MIB for untraced drivers, who does MIB appoint to deal with the negotiations

A

In this case as there are no insurers concerned, they will appoint an MIB member on rota basis

91
Q

How are the claims for untraced drivers funded

A

A levy is imposed on MIB members

92
Q

What are the new agreements 2017 for untraced drivers agreement

A
  • no exclusions for vehicle damage, where vehicle damaged was uninsured
  • damage to property excess 400 pounds
  • damage to property is recoverable provided it’s accompanied by significant injury
  • Significant injury is defined as death/injury from two or more nights of inpatient treatment or three sessions or more of hospital out-patient treatment
  • claimant is required to report the accident to the police as soon as reasonably if requested by the MIB. And can request an appeal if the report is unreasonable
  • interest on general damages run from the date of the accident
  • no exclusion for death/injury/damages in the course of the terrorism
  • awards to children and protected parties are subject to approval by arbitrator in all cases
  • MIB is not liable for a claim where a claimant has received or entitled to receive indemnity from any person other than criminal injuries compensation authority
  • There is a scale of fixed costs
  • MIB can’t ask for a lower award where there is an appeal against the original award
  • provisions for the costs of arbitration
93
Q

What are the changes that the new agreement 2017 bought to uninsured drivers agreement

A
  • exclusion of liability for damage to a vehicle that was uninsured
  • terrorism exclusion
94
Q

How many ways can insurer settle a claim

A
  • Money Payment
  • Repairs payment
  • Replacement
  • Reinstatement
  • Third parties payment
95
Q

When do Reinstatement and replacement occur

A

They can only occur if stated in the policy,if not then the insured is entitled to financial compensation

96
Q

Which is the most common way of settling claims

A

Payment of money

97
Q

By what means are cash payment

A

Cheque or bank transfer

98
Q

Which policies are always paid out in cash payment

A

Most commonly liability, business interruption and certain other types of insurance

99
Q

In the case of liability insurance other than employer’s liability how is payment made

A

Payment is made to the third party and not the insurer

100
Q

When a payment is made to the party other than the insured, what will the insurer require

A

They will require a form of discharge by the recipient of the money,stating payment is in full and final settlement of the claim to avoid a possibility of claim being re opened

101
Q

how does payment of repairs wirk

A

insurer will ask for a written estimate of the repair and then pay the repair cost direct to the repairers

102
Q

If the size of the repair is large like in Motor, what shall the insurer do

A

They will appoint a specialist to advise them on the matter of repair. In motor repairs are often by utilizing authorized repairers

103
Q

Replacement is commonly used in which insurance

A

It’s used in glass insurance

104
Q

What do glaziers offer insurers

A

They offer favorable discounts to insurers on replacement of glass, as they are given large amount of business by the insurers

105
Q

When is Reinstatement used

A

Not common around insurers,it is used in the case of extensive damage or complete destruction let’s say a building, insurers take control of the repair and rebuilding themselves

106
Q

Why is is reinstatement not seldom a course of action

A

This is because insurers accepting the responsibility to pay the full amount even when it exceeds the sum insured

107
Q

Third Parties(Rights against Insurers)Act 2010 before Insurance Act 2015 amendment took into account

A

Took into account changes in insolvency laws, its main purpose was to simplify compensation procedures when an insured becomes insolvent

108
Q

Under Third Parties (Rights against insurers )Act 2010, what is the third party not required to do

A

They don’t need to obtain judgement against the insolvent insured before issuing a claim against the insurers

109
Q

Under Third Parties (Rights against insurers )Act 2010,the liability of the insured to the insurer must

A

the liability must be established before any rights against the insurers can be enforced, this is achieved by Court declaration

110
Q

On insurers defense under the third parties (rights against insurers)Act 2010 what does this Act restrict

A

It restricts the reliance on policy condition that the insured is required to fulfill like notifications and claim cooperation provisions, so as to not penalize third parties for detrimental conduct of the insured

111
Q

What is the pay first clause

A

The insured is required to pay sums due to the third party before claiming under policy

112
Q

What does the Third Parties(Rights against Insurers)Act 2010 render pay first clause

A

It renders this clause ineffective

113
Q

Third Parties(Rights against Insurers)Act 2010 prevent the use of limitation defenses. What are limitation defenses

A

This is a situation where by proceedings start against the insured during the limitation period but proceedings for declaration against the insurers fall outside the limitation period

114
Q

Under Third Parties(Rights against Insurers)Act 2010,third party can request for documents from the insured when they believe that

A
  • a person is liable
  • that person has insurance
  • the right to claim has transferred to the third party
115
Q

Under Third Parties(Rights against Insurers)Act 2010, third party can request information from the insurers, within how many days should they be answered

A

Within 28 Days, information should also include whether the insurer told the insured that will not pay the liability of the claim under the policy

116
Q

In which situations to the Third Parties(Rights against Insurers)Act 1930 still apply

A

It continues if both the insured’s liability and entry to formal insolvency process occurred before 01/08/2016

117
Q

Under Third Parties(Rights against Insurers)Act 2010 what happens if a third party makes a claim against a dissolved insured company

A

The dissolved insured company doesn’t need to be restored to the register of companies for its insurers to be pursed

118
Q

In situations where both the insured and insurer are insolvent then

A

If eligible, third party claimant can claim under the Financial Services Compensation Scheme (FSSCS)

119
Q

Enterprise Act 2016 amended by the Insurance act 2015 states that

A

Re insurers/Insurers should pay their sums due following a claim in reasonable time, if not it gives policyholders the right to claim damages if re insurer/insurer’s unreasonable delay causes additional loss

120
Q

When the insurer pays total loss of an item, who is entitled of the salvage

A

Under property/Motor Insurance policy, if the insurer pays total loss then they are entitled to receive the benefit of the salvage

121
Q

In Motor Insurance if the insurer keeps the salvage,what do they do with it

A

They sell it through Specialist Salvage Company to minimize claims cost

122
Q

What happens to the claim payment if the insured is allowed to retain the salvage

A

The claim payment is reduced accordingly because if they were to retain both they would receive in total more than an indemnity settlement

123
Q

What condition do most insurers put in their policy wordings

A

Following a settlement of a c claim, any salvage becomes property of the insurer

124
Q

Why is accuracy in reserving claims very important

A
  • insurers are required to submit financial statement each year to the PRA,these statements feature outstanding claims
  • Estimated claim costs, when added to the cost of claims already paid out provides the underwriter with information needed to set adequate premium rates for each class of b’ness
  • If this important element of liability is kept up to date and adequately estimated, then the insurers profitability can be clearly seen at anytime
125
Q

Accurate claim reserving for an insurer will involve

A
  • examining past data claims, including claim amounts
  • using these past data and trends to take into account of changes in the law/inflation and other eternal influences to forecast projected costs
126
Q

At case level,what are the claim handlers required to do

A

They need to examine each individual claim and asses its value, and this assessment needs to be reviewed and updated regularly as the claim progresses and more information on the claim is available

127
Q

What are the methods of Claims Recovery

A
  • Contribution
  • Subrogation
  • Rights of Recovery
128
Q

For where there is Contribution, how does an insurer recover from other insurers that also cover the same loss

A

Insurer will write to the other insurers setting out all the particulars of the claim, including copies of the claim form and relevant paper work like invoices

129
Q

For Subrogation how do the insurers recover their claim

A

They will generally contact the third party immediately with a letter setting out the reason it believes the third party is at fault. They prefer to deal with other insurers thus will request to forward it to their own insurer immediately

130
Q

What is the speed of recovery for monies for subrogation

A

It will depend on how straightforward the case i.e if third party insurer accepts the liability or not

131
Q

When does Right of recovery arise

A

This situation arises where the lost/stolen item is found after the insurer has settled the insurers claim

132
Q

For when rights of recovery is used, in practice what does the insurer prefer

A

They prefer to have their claim reimbursed and the insured to keep the recovered item, but this is sometimes not practical if the insured has replaced the item with the amount from the claim payment

133
Q

What opinion did the FOS offer on Recovery of Rights

A

The insured should always be given the option of first refusal

134
Q

What does the insurer do with the item recovered

A

The insurer can sell it a salvage and set monies received against claim costs

135
Q

ABI estimated how much money goes undetected on fraud

A

1.3 billion pounds

136
Q

How much do insurers invest each year to identity fraud

A

200 million pounds

137
Q

What ABI’s figures also revealed

A
  • Fraudulent Motor Insurance Claims rose to 775 million pounds in 2016- 67,000 cases
  • Organised frauds fell down 22% on 2016 frauds worth 158 million pounds
  • Cases of 449,000 of confirmed or suspected application fraud
  • Fraudulent property insurance claims fell - down by 11% in 2016 value of 100 million pounds 22,000 cases
138
Q

What are organised Frauds

A

Like staged Motor Accidents

139
Q

What is application fraud

A

People lying or withholding information to try and get a cheaper cover

140
Q

The decrease in organised fraud was the reflection of whose work

A

It was the reflection of the work of the Insurance Fraud Bureau and Insurance Fraud Enforcement Department

141
Q

What do fraudulent claims include

A
  • bogus claims
  • misrepresentation of claims
  • inflated claims
  • multiple claims
142
Q

In the case of fraud when do insurers report to the ABI

A

Where there has been a conviction or caution issued or where there is a compelling evidence of fraud

143
Q

What do the ABI’s fraud statistics provide

A

They provide an indication of the volume and value of fraud detected by the industry

144
Q

What did the Insurance ACT 2015 clarify on what the insurer should do in the case of fraudulent claims

A

The insurer is not held liable to the claim and if any claim has been made in relation to the fraudulent claim are recoverable by the insurer and is entitled to refuse all claims occurring after the fraudulence act and after giving the insured a notice may treat the contract as terminated with effect from the time of the fraudulent act

145
Q

When does termination of a contract affect insurer’s liability

A

It will affect insurer’s liability under contract for claims occurring after a fraudulent act and not before, all the prior claims are payable

146
Q

What happens after contract is terminated due to fraudulent acts

A

Premium are non-refundable at the discretion of the insurer

147
Q

What are the three bodies that deal with Fraud Prevention

A
  • The Insurance Fraud Bureau
  • The Insurance Fraud Investigators Group
  • The Insurance Fraud Register
148
Q

What is the Insurance Fraud Bureau

A

It’s a not-for-profit organisation funded by the insurance industry, focusing on detecting and preventing organised and cross country insurance fraud

149
Q

What is the insurance fraud bureau (IFB)current focus

A

It current focus is on personal lines i.e. motor/home/personal injury claims

150
Q

What is the Insurance Fraud Investigators Group (IFIG)

A

this a members’ not-for profit organisation dedicated to the detection and prevention of insurance fraud

151
Q

What is the aim of insurance Fraud Investigators group

A

It aims to tackle the growing problem of insurance fraud in the U K and disrupt insurance fraudster

152
Q

What is the Insurance Fraud Register(IFR)

A

This complements the work of the Insurance Fraud Bureau in detecting fraud and Insurance Fraud Investigators group in prosecuting fraudsters

153
Q

How does the Insurance Fraud Register work

A

It will add identity of an individual/policyholder/third party/suppliers/professional enablers all who have shown to have acted in a fraudulent manner towards the insurer in their database

154
Q

How does the insurance fraud register load their data

A

Data must be done in accordance with clearly documented set of rules and compliance with these is mandatory for all users

155
Q

How many people in the insurance market utilize the Insurance Fraud Register

A

Over 50% of general Insurance Market and their is ongoing work to bring on board a size able proportion of the remaining market

156
Q

The Insurance Fraud Bureau and The Insurance Fraud Register is composed of

A

Essentially Insurer’s Organization

157
Q

The Insurance Fraud Investigators Group is composed of

A

Draws its membership from insurers/investigators/loss adjusters/lawyer /law enforcement agencies

158
Q

Which organisation was acknowledged by the government as Specified Anti-fraud organisation

A

The Insurance Fraud Investigators Group for the first time by the gov’t under the Serous Crime Act 2007

159
Q

In 2017 a new governance structure was announced encompassing

A

The Insurance Fraud Bureau, Insurance Fraud Enforcement Department and Insurance Fraud Register, controlled by a two-tie board

160
Q

The Insurance Fraud Bureau board also added representatives from

A

Lloyd and Association of British Insurers

161
Q

The new structure also formed the General Insurance Fraud Committee, which provides

A

It provides technical support and direction for the the Insurance Fraud Bureau, Insurance Fraud Enforcement Department and Insurance Fraud Register,

162
Q

What is one of the initiative of the General Insurance Fraud Committee

A

It’s 2020 strategy vision is to extend the scope of the Insurance Fraud Bureau in both property and commercial liability claims, so as to identify networks of fraud in commercial lines across the industry

163
Q

What are the measures undertaken to detect fraud in the insurance industry

A
  • Claims and Underwriting exchange
  • Art Loss Register
  • Motor Insurance
  • Claims Handler
  • Technology
164
Q

What is the claims and underwriting exchange(CUE)

A

This is a computerized register of information for personal lines cases from insurance proposals,claims and renewal forms

165
Q

How does the Claim and Underwriting Exchange assist insurers(its members)

A

The members submit their claims data on an individual claimants to the database and check there true claims history, helps combat fraud

166
Q

The Art Loss Register(ALR)

A

This is a collaboration between the insurance industry and the art world as a response to the increase in art theft

167
Q

The Art Loss register relies on

A

IT’s operation relies on subscriptions from insurer

168
Q

What are the objective of the Art Loss Register

A
  • increase the recovery rate of stolen art and antique

- to defer theft by making it more difficult to resale stolen articles

169
Q

The Art Loss Register is available to

A

Insurance industry, art trade, law enforcement/custom agencies, collectors and museums

170
Q

Why was the Motor Insurance anti-Fraud and Theft Register set up(MIAFTR2)

A

It was set up to help combat fraud relating to motor vehicle and contains detail of all total loss and theft claims. Insurers can access this register

171
Q

What is required by the Fourth Motor Insurance Directive

A

It requires all member states of the EU to maintain a national database for every insured vehicle

172
Q

In the UK what is the database that contains details of every insured vehicle

A

Motor Insurance Database operated by the Motor Insurance Bureau

173
Q

What is the Motor Insurance Database designed to do

A

It is designed to make it easier to pursue cross border claims and also help enforce compulsory motor insurance requirement

174
Q

Why do the enforcement agencies and police use the motor insurance Database

A

They are used to tackle uninsured drivers, and have the power to remove uninsured vehicle from the UK roads. The MID is available in real time by the police officer to ensure insured status of motorists

175
Q

How long does an insurer have to submit basic policy information about each insured to the Motor Insurance Database

A

For private cars they have 7 Days and Commercial Risk 14 Days

176
Q

What is the role of claims handler

A

The claim handler plays a vital role in detecting fraud

177
Q

What are the common indicators of fraudulent claims that a claims handler detects

A
  • beware if a claim is made right after policy inception/renewal
  • claim where there are no documentation for lost items
  • -too much documentation especially for a small item
  • insured changes their story regarding the claim
  • loss not reported to the police
  • poor claim history or similar claims have been made
  • claim is not consistent to the insured’s lifestyle
178
Q

What types of software are being developed to help detect fraud

A

Software that combine artificial intelligence and voice recognition technology to detect and interpret emotions and linguistics to assess credibility of an insurance claim

179
Q

If fraud is not detected what are the consequences to the insurer

A

If Insurer doesn take fraud in prevention seriously they will suffer a deficit in profit.The claim cost will increase and impacting pricing of premiums making them less competitive in the market. Even gain a soft touch reputation when it comes to fraudulent claims

180
Q

If fraud is not detected what are the consequences to the insured

A

Genuine insured as a result of fraudulent claims being paid in an increase in premium

181
Q

If fraud is not detected what are the consequences to the insured

A

The fraudulent claimant after succeeding in receiving monies of a claim there will be temptation to continue the practice

182
Q

What is a limitation period

A

This is a fixed period of time during which formal civil proceedings must be started

183
Q

Limitation period will depend on

A

The limitation period will depend on the type of civil claim

184
Q

Why is there a limitation period

A

This is because its essentially public policy. As it is deemed unfair and against policy for individuals to be perpetually exposed to wrongful-acts/omissions

185
Q

When does the limitation period start

A

It will start to run at the time the cause of action actually arises. All the facts which are required must exist before the limitation period starts

186
Q

What are the limitation period for contract/arbitration award/debt/negligence/breach of trust/tort

A

A claim must commence in the courts within 6 years of the date claim incurred/date of knowledge

187
Q

What are the limitation period for personal injury/fatal injury/illness

A

A claim must commence in the courts within 3 years of the date claim incurred/date of knowledge

188
Q

What are the limitation period for Defamation/malicious falsehood

A

A claim must commence in the courts within 1 years of the date claim incurred/date of knowledge

189
Q

What are the limitation period for recovery of land

A

A claim must commence in the courts within 12 years of the date claim /date of knowledge

190
Q

In personal injury Under the limitation Act of 1980 what is the date of knowledge

A

This is the date the claimant becomes aware of

  • the injury is significant
  • identity of the defendant
  • injury is attributed in whole or part to the negligent act/omissions/breach of duty of the other party
191
Q

The Limitation Act 1989 applies to which claims

A

It applies to civil claims only and not criminal acts

192
Q

What is the statutory period limit for criminal acts

A

There are no statutory limits on the prosecution of these crimes in the UK except for summary offences (ones tried in the magistrate court) which are brought within 6 months

IF 2 (13 decks)

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