claims management.iffco tokio gi

Claims management

Acknowledgement

I take this opportunity to express my gratitude towards the individuals who played a

great role in the successful completion of this project.

First of all, I would like to thank my guide and mentor, Mr. Saurabh Singh-Head

MumbaiCSC, Mumbai. Who was a constant source of guidance and support. I am

immensely thankful to him for taking out time from his busy schedule and providing

me with valuable inputs.

I am thankful to my other mentors Praveen Mohan, Dr.Bhavini Mistry, Vibhas Jha,

Milind, Sudish and Pranjali for their knowledge sharing and friendly advices, which

helped me to finish this project.

Last but not the least, I am grateful to my alma mater, XIMB and Mr. Srikanth Charan

for giving me the opportunity to work on this project in IFFCO TOKIO which was an

enriching experience throughout.

Raja Chaitanya Vikram. Gudelli

Xavier Institute of Management, Bhubaneswar

Summer Intern, IFFCO-TOKIO, Mumbai CSC, Mumbai.

Claims management

Executive Summary

IFFCO TOKIO Mumbai CSC process all the claims which are registered in Maharashtra and Goa, the claims like Fire, Engineering, Marine, Motor and health etc, each claim regarding to certain policy having a separate departments to process certain claim. General insurance being a market driven service industry, the customer has to be Kept satisfied. With so many options available, a customer once lost is most likelya loss forever. Claim settlement can be used as a marketing tool. Brining in a new Customer is much more costly than retaining the existing ones. Insurance provides financial peace against risks which are giving financial loss. In insurance, claims procedure plays an important role.. Depending on the claim, certain list of documents need to process the claim, generally the procedure is the insured claim against certain loss in branch office, then the claim will come to respective CSC, after respective manager will process the claim.

General diagrammatic representation of claim process

Claims management

Table of Contents:

S.No Topic Page no.1 Introduction 52 Claims procedure 83 The fire insurance claims procedure 94 Engineering insurance claims 135 Health insurance claims 146 Reimbursement Claims 177 Cashless claims 178 Emergency hospitalisation 189 Planned hospitalisation 1810 Medishield(Individual) 1912 Personal accident 2012 Travel protection policy 2614 Motor vehicle (Private & two wheelers) claims 2815 Marine Insurance 3216 Inland transit(rail & Road) 3417 Burglary Claims / Money Insurance / Fidelity

guarantee insurance policies37

18 Machinery Breakdown 3719 Household goods in transit 3820 Erection all risk insurance policy 3821 Contractors All Risks Insurance 3822 Machinery Loss of Profits Insurance Policy 3923 Marine Cum Erection All Risks Insurance

Policy39

24 Boiler & Pressure Vessel Insurance Policy 3925 Electronic Equipment Insurance Policy 3926 SWOT Analysis 4027 Observations 4128 Conclusion 41

Claims management

IFFCO TOKIO General Insurance (ITGI) is one of the leading insurance companies in India, established on December 4, 2000. A joint venture between the Indian Farmers Fertilizer Co-operative (IFFCO) and Tokio Marine and Nichido Fire Group, IFFCO-TOKIO offers an extensive collection of customized policies that cater to a wide array of customers, ranging from farmers to even the automobile manufacturers. From a GWP (Gross Written Premium) of Rs. 2,130 million in 2001-02, IFFCO TOKIO General Insurance has come up a long way to become one of the most prominent players in the industry with a GWP of Rs. 12,350 million in 2007-08.

IFFCO TOKIO has been the pioneer in underwriting mega policies for fertilizer as well as automobile company in India. It gets the technical support from Tokio Marine from reinsurance and underwriting. It also gets assistance from Tokio Risk Consulting (TRC) on Risk Management. IFFCO TOKIO General Insurance has also crafted its name in various products like Credit Insurance, P&I Insurance, Fine Arts Insurance and Errors and Omissions Policy for IT Sector.

Currently, IFFCO TOKIO General Insurance has a pan-Indian presence with 51 ‘Strategic Business Units’. It also has an extensive network of more than 110 offices across the country.

Subsidiary

IFFCO TOKIO is also the sole Indian insurance company to have fully-owned distribution channel (IFFCO-TOKIO Insurance Services Ltd.) for serving retail customers. Established on August 1, 2003, it has a workforce of more than 1000 employees spread over 200 towns across India. Currently ITIS has over 90 ‘Lateral Spread Centres’ (LSC) as well as 140 ‘Bima Kendras’ (BK). More than 1500 employees work for ITIS.

Claims management

Promoters

In IFFCO-TOKIO General Insurance, IFFCO holds 72.64% of share, while 1.36% of the share is held by its associate M/s Indian Potash Ltd. The rest 26% of IFFCO-TOKIO share is held by TOKIO Marine Asia Pte. Ltd.

ProductsIFFCO TOKIO General Insurance offers a wide range of products to its customers. Following are the products offered by IFFCO TOKIO:

Commercial Line

• Bankers Blanket• Boiler & Pressure Plant• Burglary Insurance• Consequential Loss• Contractors All Risk• Contractors Plant & Machinery• Electronic Equipment• Erection All Risks• Fidelity Guarantee• Industrial All Risks• Machinery Breakdown• Machinery Loss of Profit• Marine Cargo• Money Insurance• Product Liability• Public Liability Industrial• Public Liability Non-Industrial• Standard Fire & Special Perils• Workmen's Compensation

Claims management

Retail Line

• All Risk Insurance• Critical Illness Policy• Group Personal Accident• Home & Family Protector• Home Suvidha• Individual Medishield• Individual Personal Accident• Industry Protector• Motor Private Car• Office Professional Establishment• Swasthya Kavach (Family Health) Policy• Trade Protector• Trade Suvidha• Travel Protector

Speciality Line

• Aviation Insurance Policy• Barish Bima Yojna (Weather Insurance)• Credit Insurance• Errors and Omissions (Technology) Policy• Fine Art Insurance – Art Dealers & Gallery Owners• Fine Art Insurance – Private Collectors• Jeweller's Block• Marine Hull & Machinery• Multi Modal transport (MTO)• Sagar Bandhu Bima Policy

Claims management

Mumbai CSC dealing all the claims which are registered in Maharashtra and Goa,General Claims Procedure

All insurance contracts are based on the information provided by the insured in the proposal form. The proposal form forms the basis of insurance contracts.

Some important points, which would help you in the claims procedure. The loss or damage should be reported to the insurer immediately. On receipt of claim intimation, the insurer will forward a claim form. Submit the completed claim form along with an estimate of the loss to the

insurer. It is preferable to submit an itemized estimate with separate values. The insurer will arrange for inspection of the damaged items to assess the loss.

In case of major losses, a specialist-licensed surveyor is deputed. The insured has to provide the required documents to substantiate the extent of

loss. In case the cause of loss is not established, it is for the insured to prove that the

loss or damage has occurred due to an insured peril. On agreement of claim amount between the insured and the insurer, the claim is

settled. Excess as stated as per the Policy terms and condition will be deducted from

the claim payable.

In view of varied nature of policies, certain points distinct to individual policies, in addition to the above, are listed below: (Please note that the documents mentioned are indicative and based on the circumstances of the claim, insurer may request for additional documents)

THE FIRE INSURANCE CLAIMS PROCEDURE

Claims management

As soon as a claim occurs, please intimate immediately to our Regional Office. Our

Claims management

claims officials will be happy to help you with the claim procedure. INITIAL STEPS

1. The first step with any potential claim under a policy of insurance is to notify the insurance company of the claim. Normally people do this by contacting their broker, but in some circumstances, an insurance company is set up to receive claims directly. You are obliged under the terms of your policy to give notice forthwith to your insurance company of your claim, in writing.

2. Your insurance company will appoint an adjuster to handle your claim. The adjuster’s role is to explain the claims process to you and to adjust your claim. It is important to keep in mind that the adjuster is hired by the insurance company and takes instructions from your insurance company.

3. There are various components to your house insurance, and it is important to be familiar with the types of coverage and the limits which are applicable. Some of the types of coverage are discussed below.

THE BUILDING1. In circumstances of a total loss, your insurance company will be obliged to pay

for your home to be rebuilt. Your insurance company will first determine the replacement value of your home (ie. the cost to rebuild it).

2. In some circumstances, it can be difficult to determine the appropriate replacement value. The replacement value will be based on the square footage of the home, the quality of the finishings, quality of construction and other factors.

3. If you have photographs or videos of your home, these can be very helpful. In the majority of cases where there is a total loss, your insurance company may not insist that the house be built exactly the same as the one that was destroyed.

4. In a total loss, the insurance company will have to assess whether the foundation is salvageable or not, and will normally retain an engineer to do an assessment of the property.

5. Once the replacement value has been determined, you will then be in a position to hire a contractor to rebuild your home, with the insurance company paying the lesser of the following towards the cost of construction

Following information needs to be furnished by you while intimating a claim: Your Contact Numbers Policy Number Name of Insured person, Date & Time of accident, Location of Loss, Brief description on how the accident took place, Extent of loss Place & contact details of the Insured Person (in case person intimating the

claim is other than the insured person.

IMMEDIATE ACTION AFTER LOSS

Claims management

Take measures to extinguish the fire and all steps to minimize the extent of loss. Inform the Fire Brigade and co-operate with them but don't forget to Obtain the

Fire Brigade Report and bill for fire fighting expenses, because these expenses are payable under the policy.

Intimate the insurance company with a rough estimate of loss as early as possible and obtain your claim form.

In case of damage due to natural calamities like storm, floods, lightning, obtain the meteorological report for the weather broadcast at the time of disaster.

Do not dispose the Salge until advised by the surveyor or Insurance Company.

DOCUMENT CHECK LIST

BASIC DOCUMENTS:

Claim Form duly filled in & signed. Claim bills : Detailed claim bills with necessary bills/vouchers. F.I.R, if filed. Fire Brigade Report (internal or external or both as the case may be). Forensic Departments report, if applicable. Laboratory test report together with the mandate given, if applicable. Record of Labour involved in activities related to claim. Original Repair/ Replacement Bills with receipt. Photographs if arranged. Departmental Note on the incident. Meteorological report: In case of natural calamities like floods, cyclone,

earthquake etc) or News paper cutting.

Any pending documents yet to received from client we will send a reminder letter to him regarding pending documents

Claims management

REMINDER LETTER FORMAT

ENGINEERING INSURANCE CLAIMS

Claims management

As soon as a claim occurs, please intimate immediately to our Regional Office. Our claims officials will be happy to help you with the claim procedure. Details of Regional offices can be found in Reliance General Insurance Office locator.

Following information needs to be furnished by you while intimating a claim:

Your Contact Numbers Policy Number Name of Insured person, Date & Time of accident, Location of Loss, Brief description on how the accident took place, Extent of loss Place & contact details of the Insured Person (in case person intimating the



Ensure that all the steps have been taken to minimize the extent of loss or damage.

In case of loss or damage by fire, inform the Fire Brigade and co-operate with them but don't forget to Obtain Fire Brigade Report and bill for fire fighting expenses, because these expenses are payable under the policy.

Intimate the insurance company with a rough estimate of loss as early as possible.

In case of damage due to natural calamities like storm, floods, lightning, obtain the meteorological report for the weather broadcast at the time of disaster.

Furnish all information and documentary evidence as the insurance company may require.

In case of loss or damage due to theft or burglary, inform the police authorities. Preserve the parts affected and make them available for inspection by a

representative or surv eyor appointed by the insurance company. The Salvage materials should be disposed off at best available prices which will

help in minimizing your loss to a certain extent. In case of loss or damage to third party, you may forward immediately any

notice of claim received from a third party without admitting liability. You should not offer, admit, compromise or promise any payment to third party without the consent of the insurance company in writing.

HEALTH INSURANCE(Medi shield) CLAIMS

Claims management

ITGI offering 4 types of health insurance policies,

Claims management

Individual Medishield Swasthya Kavach (Family Health) Policy

Group Personal Accident

Critical Illness Policy

Provisions:

To provide prompt claims servicing to you we have appointed Third party administrator duly licensed by IRDA.

Our TPA will be happy to provide you with services in a hassle free manner within the terms and conditions of your Health policy. They will provide you the following claims services

"Cashless Service" at all our Network Providers for all eligible ailments/conditions.

Processing and settlement of claims under the MEDICLAIM policy with a time bound approach.

24 hours Call Centre Service.

As soon as a claim occurs, please intimate to the TPA Help line/Toll free number as mentioned in your Health Card

AS OF NOW ITGI CLAIMS ARE PROCESSED THROUGH FOLLOWING TPA`S:

S.No Name of TPA Contact mail id or Site1 Paramount Health Care [email protected] FHPL [email protected] Raksha [email protected] E-Meditek [email protected] ICARE [email protected] TTK [email protected] DHS [email protected] MEDIASSIST [email protected] MD-INDIA [email protected] Vipul www.vipulmedcorp.com

Claims management

http://www.iffcotokio.co.in/ind_medisheild.html

http://www.vipulmedcorp.com/

mailto:[email protected]









http://www.iffcotokio.co.in/Critical_Illness_Policy.html

http://www.iffcotokio.co.in/Group_Personal_Accident.html

http://www.iffcotokio.co.in/swasthya-kavach.html


Your Contact Numbers Policy Number and Membership ID number (as reflecting on the Health Card) Name of Insured person who is Sick or Injured, Nature of Sickness/Accident, Date & Time of Loss in case of accident, commencement date of symptom of

disease in case of sickness, Location of Loss, Place & contact details of the Insured Person.

CLAIM PROCEDURE:

CLAIMS ARE BROADLY OF TWO TYPES:

1. Reimbursement Claims2. Cashless claims.

Claims management

1.REIMBURSEMENT CLAIMS

Upon discharge, you need to collect the bills, discharge summary and other relevant documents from the hospital. Documentation should also include diagnostic reports and medical advice, if any, from the doctor pertaining to the post-hospitalisation period and cash receipts, if any.Make sure you verify the completed bill before signing the same.

Once you are out of the hospital, you have to submit all the original documents related to your treatment to the insurer (if claims processing is done in-house) or to the designated TPA (third party administrator) before 30days.

If you have incurred any costs prior to, and after, the hospitalisation period, you need to submit these documents too, provided they are related to the cause of hospitalisation. The norm in the industry is that expenses pertaining to 30 days prior to hospitalisation are to be reimbursed by the insurer.

2.CASHLESS CLAIMS:Procedures for Cashless Claims:

Cashless Service is the service wherein you need not pay any amounts either as a deposit at the time of admission or for the hospital bills at the time of discharge. This facility is available only at our Network Hospitals. To avail the "Cashless Service" you need to fill "Cashless request form" available in the network hospital get an authorization from TPA. This authorization along with a copy of the card issued by TPA has to be given to the Network Provider at the time of admission. Please Note: TPA will authorize "Cashless Service" at the Network Providers in all cases eligible under the insurance policy.

"Cashless Service" may be denied in some of the situations as listed below.

In case of any doubt in the policy terms with respect to the present ailment. If the information sent to TPA is insufficient to confirm coverage. The ailment/condition etc. not being covered under the policy.If the request for preauthorization is not received by TPA in time.

Denial of "Cashless Service" is not denial of treatment. You can continue with the treatment, pay for the services to the hospital, and later send the claim to TPA for processing and reimbursement.

Claims management

A) Emergency hospitalization

Step 1. Take admission into the hospital.

Step 2. Within 24hrs inform to TPA about the hospitalization

Step 3. Fax the pre-authorization form by you/hospital along with necessary medical details like investigation report etc to TPA at the number mentioned in your health card.

Step 4. A) If authorization for "Cashless Service" from TPA has been received by hospital

At the time of discharge settle the hospital bills in full and collect all the bills documents and reportsPay for those items that are not reimbursable under the MEDICLAIM policy.Verify the bills and sign on all the bills.Leave the original discharge summary and other investigations reports with the hospital. Retain a Xerox copy for your records.

OR

B) In case "Cashless Service" was denied by TPA

At the time of dischargeLodge your claim with TPA for processing and reimbursement

B) Planned hospitalization

Step 1. Please co ordinate with your doctor and the hospital and send in all the details of your planned hospitalization including the plan of treatment, cost estimates etc. to TPA. This should be sent to TPA at least 2 days prior to the admission.

Step 2. A) If authorization for "Cashless Service" from TPA has been received

At the time of admission, hand in the authorization letter and a photocopy of your ID card to the hospital.Pay for those items that are not reimbursable under the MEDICLAIM policy.Verify the bills and sign on all the bills.Leave the original discharge summary and other investigations reports with the hospital. Retain a Xerox copy for your records.

Claims management

Medishield(Individual)

Covered Not covered

Hospitalization Pre-hospitalization Post - Hospitalization. Emergency Assistance Service Local Ambulance Service Family discount is available (5%

for 2 people, 10% for 3 or more people).

Benefits / rates given in the leaflet are indicative MaximumEntry Age: 5- 55 years (medical reports required above 45 years of age)

Rates inclusive of service tax.

1.Diseases, which have been in existence at the inception of the policy2.Illness that commenced during the first 30 days of inception of the first policy.3.Cataracts, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis and related disorders, in the first year of insurance.

Note: on renewal, these exclusions shall not apply. For a complete list of exclusions, refer to the policy.

PERSONAL ACCIDENT:

Claims management

CALCULATION OF SUM INSURED IS BASED ON BELOW TABLE

TABLE OF BENEFITS PERCENTAGE OF CAPITAL SUM INSURED

1. Death 1002. a) Loss of sight (both eyes) b) Loss of two limbs c) Loss of one limb and one eye

100100100

3. a) Loss of sight of one eye b) Loss of one limb

5050

4. Permanent Total and absolute disablement

100

5. i) Loss of toes-all ii) Great-both phalanges iii) Great-one phalanx

iv) Other than great, if more than one toe lost each

20521

i) Loss of hearing – both ears ii) Loss of hearing – one ear

5015

Claims management

c) Loss of Speech 50d) Loss of four fingers and thumb of one

hand 40

e) Loss of four fingers 35f) Loss of thumb i) Both phalanges ii) One phalanx

2510

g) Loss of index fingeri)Three phalangesii)Two phalangesiii)One phalanx

1084

h) Loss of middle fingeri) Three phalanges

ii) Two phalanges iii) One phalanx

642

i) Loss of ring fingeri)Three phalanges

ii)Two phalanges ii)One phalanx

542

j) Loss of little finger i)Three phalanges ii)Two phalanges iii)One phalanx

432

k) Loss of Metacarpals i) First or second (additional) ii)Third, fourth or fifth (additional)

32

l) Any other permanent partial disablement

% as assessed by Doctor

6. Temporary Total disablement benefit at the rate per week

1% of C.S.I or Rs.6000 whichever is lower.

Special Inbuilt Benefits Under The Policy In Addition To Capital Sum InsuredA. In the event of death of Insured Person

outside his/her Home, transportation cost for carriage of dead body to Home including funeral charges is payable.

2% of Capital Sum Insuredor 2,500/- (Two thousand five hundred) whichever is lower.

B. Cost of Clothing damaged in the Accident as described above and liability is admitted by US.

Rs. 1000 (one thousand) per insured person any one accident or actual expenses whichever is lower.

Claims management

C. Ambulance charges for transportation

of Insured person to Hospital following Accident which result in liability having been admitted by US as per 1 to 6 of Table of Benefits.

Rs. 1000 (one thousand) per insured person any one accident or actual expenses whichever is lower.

D. Education Fund In the event of death, permanent total

disablement i.e. 1 to 4 of Table of Benefit of Insured Person, WE will approve compensation towards Education Fund for dependent children as belowa) For one child upto the age of 23 yrs.

b) For more than one children upto the age of 23 yrs.

-10% (Ten percent) of C.S.I Subject to a maximum of Rs. 5000/--10% (Ten percent) of C.S.I Subject to a maximum of Rs. 10000/-

E. Loss of Employment In the event of accident leading to loss

of employment as a consequence of 2,3 and 4 of table of benefits.

- Rs. 15000 or 1% of CSI whichever is lower.

Table “A” Benefit 1Table “B1” Benefit 1 to 4Table “B” Benefit 1 to 5Table “C” Benefit 1 to 6

DOCUMENTS/DETAILS REQUIRED FOR PROCESSING GPA/IPA CLAIM

1. Completed claim form clearly giving the narration &circumstance in which accident took place.

2. Medical certificate mentioning the nature of injury and disability period for which total rest is required.

3. X-rays and other diagnostic reports clearly mentioning the findings of orthopedic surgeon.

4. Medical prescriptions&cash memos for medicines and hospital charges incurred in original.

5. If the accident has occurred in public place involving vehicle or third party, then police FIR&panchanama

6. Certificate from the employer furnishing the name, Designation &coverage particulars Under GPA policy & certificate for leave of absence.

Claims management

7. Copy of the policy schedule clearly nothing the person involved and the capital

sum insured and table in which coverage done8. If the injury results in permanent disability, a clear color photograph showing

the disability and identity of the person may also be furnishedAbove all documents not compulsory, depend on the caim insurer ask the required documents, for example if the accident happened in the public place then only police FIR is needed.

IN ADDITION TO ABOVE, THE FOLLOWING DOCUMENTS ARE ESSENTIAL FOR SETTLEMENT OF DEATH CLAIMS:

1. FIR, Police Panchanama/Inquest report2. Post mortem report3. In case viscera was preserved, then chemical analysis report of the viscera from

the GH/clinic examining the same4. Original death certificate5. Any one of the following original documents for legal name –Passport, PAN

card, Voter`s identity card, Driving License letter from a recognized public authority or public servant, verifying the identity and residence of the customer.

6. Proof of the residence- Telephone bill or Electricity bill (not older than 6 months), Bank account statement bearing permanent or present residential address / written confirmation from his banker,iii. Letter from any recognized public authority, Ration card, Employer`s certificate.

Individual Personal Accident Insurance Policy

Benefits of the policy:

Education Benefit: In the unfortunate event of death or loss of limbs/eyes or permanent total disablement of the Insured, the education cost of dependant children is covered under the Policy upto specified limits.

Employment Benefit:This cover provides financial compensation upto specified limits in the event of loss of employment of the Insured following an accident resulting in loss of limbs/eyes or permanent total disablement.

Ambulance Benefit:If any accident results in the use of an ambulance by the Insured to reach a hospital, then the Policy will pay the necessary charges upto specified limits.

Cumulative Benefit: Under the Policy the Sum Insured amount for you and your family members under Individual and Family covers is automatically increased on renewal upto specified limits without payment of any extra premium. Besides these benefits,

Claims management

our Policy also offers benefits, like compensation for clothing damaged in an accident, expenses for carriage of dead body etc.

Extra benefits

On payment of nominal extra premium, our Personal Accident Insurance Policy can also be extended to provide a whole range of additional coverages.

Medical Expenses In addition to the death or disablement benefits, the Policy will provide reimbursement upto specified limits for medical expenses incurred for treatment following an accident.

Cost of Supporting Items If the use of supporting items like crutches, wheelchair, artificial limbs etc. becomes necessary due to injuries sustained in an accident, then the costs are reimbursed upto specified limits.

Cost of Travel If the Insured is disabled in a place other than his normal residence due to an accident, then we will pay upto specified limits for cost of travel of the injured person for returning home and also for the travel cost of any accompanying friend or relative to join the Insured and for returning home.

Exclusions for individual accident and group accident policy

Individual personal accident policy

Group personal accident policy

self-injury, suicide, venereal disease, insanity, influence of intoxicating liquor or drugs, pregnancy or childbirth, HIV or AIDS , war and nuclear risks etc.

1.Self injury, suicide, venereal disease or insanity2.Influence of intoxicating liquor or drugs3.Death due to pregnancy or childbirth4.Breach of law with criminal intent5.War and nuclear group of perils6.On duty with armed forces

Example for group personal accident policy:

If one person met with severe accident, he is suffering with permnant disability problems.

Claims management

He is working in some company where he met withan accident, Total S.I.is rs. 3lacs. then the caluculation is as belowwe have to calculate the TTD and TPDDetails:No. Days in disablement- 90 daysmedical expences- 40000salary per month- 20,000TTD compensation:Sum insured-3LTTD compensation amount =90/7*(1% of Sum insured) =90/7*3000 =38571Add Medical Expences= TTD Compensation *50/100 =38571*50/100 =19285Then TPD = 38571+19285= 57855

Permanent total disability: If the doctors gave the reports in such reports disability percentage is 20%Then Permanant total disability equals to (PTD)= (Sum insured * disability percentage) =(20000*48 months)*20% =192000Medical expences=192000*50% =96000Medical expences(Actuals)=40000Actual amount is less than calculated ,then we have to take less amounti.e., 40000Then PTD =192000+40000 =2,32,000/-

TPD= 57855/-PTD=232000/-

So we have consider the higher amount of the above which is 232000/-

Travel protector Policy:

Claims management

Object:

ITGI provide the Insurance Cover for immediate Medical Assistance required as a consequence of an Insured Person falling ill whilst abroad or sustaining an accident during the period of Insurance.

The claim procedure varies from country to country and therefore the insured should get in touch with the overseas claim settling agents of the insurers immediately.

The Insured should carry the policy document with him, which may be produced as evidence if necessary. The policy document also contains the full information as to how to get in touch with the claim settling agents for assistance.

Comparative analysis of different plans (Amount in U.S $):S No. Covers Gold 500 Gold 250 Gold 100 Silver Bronze Deductible/

Claims management

Excess

1 Medical Expense $500,000 $250,000 $100,000 $250,00 $50,000 $100

2 Dental Treatment $250 $250 $250 $250 $250 $100

3

Transportation of mortal remains or burial at local place $7,000 $7,000 $7,000 $7,000 $7,000 $100

4 Hospital Daily Allowance

$ 30 per day for 20

days

$ 30 per day for 20

days NIL

$ 30 per day for 20

days Nil 48Hrs

5Total loss of checked baggage $1,000 $1,000 $1,000 $1,000 $500 Nil

6 Checked Baggage Delay $150 $150 $150 $150 $100 12 Hrs

7 Passport Loss $200 $200 $200 $200 $200 Nil

8 Hijack Distress Allowance $700 NA NA NA NA 12 Hrs

9Financial Emergency Assistance $250 Nil Nil Nil Nil Nil

10 Personal Accident $25,000 $25,000 $25,000 $25,000 $15000 Nil

11 Personal Liability $100,000 $100,000 $100,000 $100,000 Nil Nil

12 Countries covered Worldwide Worldwide Worldwide

Worldwide excluding U.S.A & Canada

Worldwide excluding U.S.A & Canada

24 Hour Worldwide Assistance-To assist you around the clock in case of any emergency when you are abroad, ITGI has tied up with PHM Global and their address isParamount Healthcare Management Pvt.Ltd.Travel Health Dept.Elite Auto House, 1st Floor,54-A, M.Vasanji Road,Chakala, Andheri (E), Mumbai- 400093 Tel: 00 91 22 40004216 / 40004219, Toll Free: 1 866 978 5205 (within USA) Fax: 00 91 22 67021259 / 260E-Mail: [email protected]

Motor vehicle (Private & two wheelers) claims

Claims management


Claims under Motor policies

Notice of an accident (not necessarily a claim) involving third parties should be reported to the insurers.

The insured may be interested to pay compensation without going into whether he is liable to pay or not. It is therefore an express condition of the policy that no claim should be admitted or a compromise arrived at, without the approval of the insurers.

In case of major claims, the insurers may be willing to defend criminal case against the driver also on the basis of which compensation claims may be decided in the civil courts.

Every accident involving third parties is required to be reported to police. M.V.Act provides that a third party victim can proceed against the insurers directly. If the alleged accident is not reported to the insurers, the insurers can consider this as violation of policy condition. In such circumstances, even if insurers are required to pay compensation by a court of law, they have an option of recovering such claim amounts from the insured for violation of specific policy condition.

Policy covers:1. Personal Accident Cover2. Third party legal liability3. No Claim Bonus4. Transfer your NCB

Sum Insured with IDVThe vehicles are insured at a fixed value called the Insured’s Declared Value (IDV).

Claims management

IDV is calculated on the basis of the manufacturer’s listed selling price of the vehicle (plus the listed price of any accessories) after deducting the depreciation for every year as per the schedule provided by the Indian Motor Tariff.

If the price of any electrical and / or electronic item installed in the vehicle is not included in the manufacturer’s listed selling price, then the actual value (after depreciation) of this item can be added to the sum insured over and above the IDV. Two wheelerITGI’s comprehensive Package Policy for two wheelers covers Loss or damage to the vehicle insured, Personal Accident and Third Party Liability.Policy Covers:

Any loss or damage caused to the vehicle due to the following natural and man made calamities.

Natural Calamities – Fire, explosion, self-ignition or lightning, earthquake, flood, typhoon, hurricane, storm, tempest, inundation, cyclone, hailstorm, frost, landslide, rockslide.

Man made Calamities – Burglary, theft, riot, strike, malicious act, accident by external means, any damage in transit by road, rail, inland waterway, lift, elevator or air.

Personal accident cover: The motor insurance provides compulsory personal accident cover of Rs. 1 lakh for individual owner driver of the vehicle insured while travelling in, mounting or dismounting from the vehicle. You can also opt for a personal accident cover for pillion rider.

Third party legal liabilityProtects against legal liability arising due to accidental damages, any permanent injury/ death of a person and/or any damage caused to the property.

Sum InsuredThe vehicles are insured at a fixed value called the Insured’s Declared Value (IDV). IDV is calculated on the basis of the manufacturer’s listed selling price of the vehicle (plus the listed price of any accessories) after deducting the depreciation for every year as per the schedule provided by the Indian Motor Tariff. If the price of any electrical and / or electronic item installed in the vehicle is not included in the manufacturer’s listed selling price, then the actual value (after depreciation) of this item can be added to the sum insured over and above the IDV.

Claim process1. Notice of accident should be filed with ITGI’s toll free number 1800 103

Claims management

5499

2. Then the claim will be initiated based on location, after intiating the claim, the surveyor appointed by respective authorised person,

3. After that surveyor would carry the survey process, like visiting the place in which accident placed and inspecting the details which are produced by insured etc.,

4. Then he ask to insured for desired documents to assess the claim.5. If any pending documents are there from insured company will rise the

reminder letter from our side to insured.6. If all the documents produced by insured based on that surveyor made the

survey report on that, then he will update to company.7. Then company review all the supported documents and if it is perfect then

the claimed amount is approved by authorised employee.8. Company will transfer the claimed amount to insured by

NEFT/EFT/DD/Ac payee cheque.

Following information regarding claim is updated on system, 1. Insured vehicle details2. Related claims( Insured has claimed any damage regarding the same assured

vehicle)3. Vehicle condition4. Documents5. Questionnaire6. Crash photos7. Interm report8. Notes9. Final report10. Claim bills

Steps to be taken in case of an accident:

Claims management

1. Notice of accident should be filed with ITGI’s toll free number 1800 103 54992. Total process of motor claim is automated like vehicle photos at the time of

incident, occurrence, time, date, mode of loss, 3. If damage is a major one, the accident may be reported before the vehicle is

removed from the spot so that the insurers can arrange for spot inspection of damage.

4. The vehicle may then be moved to a workshop, preferably to authorized workshop, for estimation of repair charges.

5. On receipt of completed claim form and estimate of repairs the insurers will arrange detailed inspection of damage and cost of repairs will be ascertained.

6. The insurers will ensure that a person duly licensed drove the vehicle at the time of accident and that the vehicle is the one insured in their books. To that end, they will verify the Registration Certificate and the Driving license of the driver who drove at the time of the accident.

7. Upon completion of the above procedure, the repairers will be authorized to carry out repairs. The insurer may undertake to settle the repair bills directly with the garage or reimburse the insured.

Motor claims processed by fully automated, the total process will be done by specially designed software

Claims management

Claims management

THIS INSURANCE COVERS ALL RISKS OF LOSS OF OR DAMAGE TO THE SUBJECT-MATTER INSURED EXCEPT AS PROVIDED IN CLAUSES 1, 2, 3 AND 4 BELOW.

Exclusions:

1. In no case shall this insurance cover loss damage or expense attributable to wilful misconduct of the Assured ordinary leakage, ordinary loss in weight or volume, or ordinary wear and tear

of the subject-matter insured loss damage or expense caused by insufficiency or unsuitability of packing or

preparation of the subject-matter insured (for the purpose of this Clause 4.3 "packing" shall be deemed to include stowage in a container or lift van but only when such stowage is carried out prior to attachment of this insurance or by the Assured or their servants)

loss damage or expense caused by inherent vice or nature of the subject-matter insured

loss damage or expense proximately caused by delay, even though the delay be caused by a risk insured against (except expenses payable under Clause 2 above)

loss damage or expense arising from insolvency or financial default of the owners managers charterers or operators of the vessel

loss damage or expense arising from the use of any weapon of war employing atomic or nuclear fission and/or fusion or other like reaction or radioactive force or matter.

2.In no case shall this insurance cover loss damage or expense arising from unseaworthiness of vessel or craft,

unfitness of vessel craft conveyance container or lift van for the safe carriage of the subject-matter insured, where the Assured or their servants are privy to such unseaworthiness or unfitness, at the time the subject-matter insured is loaded therein.

The Underwriters waive any breach of the implied warranties of seaworthiness of the ship and fitness of the ship to carry the subject-matter insured to destination, unless the Assured or their servants are privy to such unseaworthiness or unfitness.

Claims management

3.In no case shall this insurance cover loss damage or expense caused by

war civil war revolution rebellion insurrection, or civil strife arising there from, or any hostile act by or against a belligerent power

capture seizure arrest restraint or detainment (piracy excepted), and the consequences thereof or any attempt thereat

derelict mines torpedoes bombs or other derelict weapons of war.

4.In no case shall this insurance cover loss damage or expense caused by strikers, locked-out workmen, or persons taking part in labour

disturbances, riots or civil commotions resulting from strikes, lock-outs, labour disturbances, riots or civil commotions caused by any terrorist or any person acting from a political motive.

Inland Transit (Rail or Road) Clause – A(All Risks)

Exclusions1. In no case shall this insurance cover

loss, damage or expense attributable to wilful misconduct of the assured ordinary leakage, ordinary loss in weight or volume, or ordinary wear and tear

of the subject-matter insured loss damage or expense caused by the insufficiency or unsuitability of packing

or preparation of the subject-matter insured (for the purpose of this clause 2.3 “Packing” shall be deemed to include stowage in a container or lift van but only when such stowage is carried out prior to attachment of this insurance or by the Assured or their servants)

loss damage or expense proximately caused by delay, even though the delay be caused by a risk insured against

Loss damage or expense caused by inherent vice or nature of the subject-matter insured.

2. In no case shall this insurance cover loss damage or expense caused by war civil war revolution rebellion insurrection, or civil strife arising there from,

or any hostile act by or against a belligerent power capture seizure arrest restraint or detainment and the consequences thereof or

any attempt thereat Derelict mines bombs or other derelict weapons of war.

Claims management

3. In no case shall this insurance cover loss damage of expense

caused by strikers, locked-out workmen or persons taking part in labour disturbance, riots or civil commotions

resulting from strikes lock-outs, labour disturbances, riots or civil commotions Caused by any terrorist or any person acting from a political motive.

CLAIMS PROCEDURES AND DOCUMENTATION

As soon as a claim occurs, please intimate immediately to our Regional Office. Our claims officials will be happy to help you with the claim procedure. Details of Regional offices can be found in Reliance General Insurance Office locator.


1. Your Contact Numbers2. Policy Number3. Name of Insured person,4. Date & Time of accident,5. Location of Loss,6. Brief description on how the accident took place,7. Extent of loss8. Place & contact details of the Insured Person (in case person intimating the



Intimate the insurance company immediately, with a rough estimate of the loss to their nearest office or overseas agents mentioned in the policy and also obtain a claim formEnsure that all the rights of recovery against carriers, bailees or other third parties are preserved and exercised.In case of Carriage by Sea, you should send an application for survey to the Shipping company (ship survey) within 3 days of taking delivery.Obtain damage certificate/open delivery certificate/landing remarks certificate from carriers/ port trust/ airlines/ transporter etc.In case of damage due to natural calamities like storm, floods, lightning, obtain the meteorological report for the weather broadcast at the time of disaster.Do not dispose the Salvge until advised by the surveyor or Insurance Company.

Claims management

Following documents need by surveyor to process the claim

1.ORIGINAL CERTIFICATE OF INSURANCE OR COPY OF MARINE DECLARATION

proves the title to recover from Insurer must be properly endorsed used for premium calculation

2.ORIGINAL COMMERCIAL INVOICE calculates the value of the cargo identifies the insurable interest in the cargo identifies the terms of sale

3.ORIGINAL OCEAN BILL OF LADING OR AIR WAYBILL evidence of contract of carriage proof of the condition of the goods before shipment.

4.PACKING LIST -will establish evidence of the number of goods shipped 5. DELIVERY RECEIPT

identifies the last carrier evidence that the goods arrived in a damaged condition

6.LETTER OF INTENT TO CARRIERS & THEIR RESPONSES evidence of prompt notice to responsible parties evidence that the subrogation rights are protected

7. STATEMENT OF CLAIM -calculates the amount of claim 8. CANADA CUSTOMS CODING FORM -indicates amount of duty & taxes paid 9. FREIGHT INVOICE -shows freight charges paid

The following additional documents may also be needed depend on claim: 1. COPY OF CARRIER'S INSPECTION REPORT - in case of claim for damage2. LETTER FROM CARRIER THAT SEARCH HAS BEEN DONE -in case of non-delivery of entire package3. WAREHOUSE RECEIPT - if damage occurred during destuffing of containers 4. DOCK RECEIPT -in case goods arrived at port in damaged condition 5. LOADING & UNLOADING REPORT- in case of shortshipment, non-delivery and damage 6. VALUED/ITEMIZED INVENTORY AND/OR PROOF OF VALUE - in case of personal effects shipment7. ORIGINAL REPAIR ESTIMATES - in case of repairable personal effects 8. ORIGINAL REPLACEMENT ESTIMATE - in case damage to personal effects is beyond repair 9. PHOTOGRAPHS -proof of the condition of goods at arrival.

Claims management

Burglary Claims / Money Insurance / Fidelity guarantee insurance policies

Immediately report to the police and obtain a non-traceable certificate that the items are not found.

Notify insurer as early as possible.

The insurers will insist upon a letter of undertaking on a stamp paper of appropriate value - letter of Subrogation, for refunding the claim amount when the stolen property is recovered.

Obtain a final report from Police.

Insured has to provide the surveyor complete book of accounts and bills substantiating the loss on the day of incidence.

Machinery Breakdown

Immediate notification to the insurer Notice of claim and estimated cost of

repairs should be filed with the insurers to arrange for inspection.

In case of partial losses, no depreciation is charged but when the items are not insured for its present day replacement value, the items are treated as underinsured and the claim amount is proportionately reduced. Depreciation is only applied for Total Loss claims.

If an appliance is partially damaged, it should be repaired (on approval from insurance company) before it is put to use, as otherwise further loss is not covered.

Claims management

Household goods in transit:

In case any damage is suspected in transit, open delivery should be insisted upon the carrier and their certificate should be obtained.

In case of loss/damage in transit, a monetary claim should be lodged with the carrier within the time limit to protect recovery rights, without which, the claim may not be admitted.

Erection all risk insurance policy:

Folllowing documents needed for processing the erection all risk insurance policy claims

Claim form duly filled and signed

Original Repair Bills with receipt.

The amount of loss: Detailed claim bills with necessary bills/vouchers like bill for repairs/ replacement/ original invoice/ bill of entry.

Photographs if arranged Fire Brigade Report

Repair agency's report detailing their findings on Cause and the repair procedure suggested

Departmental Note on incident and repairs to be undertaken

Specification of Repair form filled by the repairer

Contractors All Risks Insurance

Claim Form duly filled in & signed. Record of Labour involved in

activities related to claim.

Inventory of Loss.

Abstract of relevant portion of Running Account Bill

Original Repair Bills with receipt.

Claims management

Photographs if arranged.

Machinery Loss of Profits Insurance Policy1. Claim Form duly filled in & signed.2. Books of Accounts.

3. Record of Labour involved in activities related to claim.

4. Details of Savings effected in Standing Charges.

5. Claim Bill.

6. Details of Increased Cost of Working.

7. Details of Trends of Business.

Marine Cum Erection All Risks Insurance Policy

1. Claim Form duly filled in & signed.2. Record of Labour involved in activities related to claim.

3. Inventory of Loss.

4. Original Repair Bills with receipt.

5. Photographs if arranged.

6. Makers report detailing Extent of Loss, Cause and suggested repair procedure.

Boiler & Pressure Vessel Insurance Policy

1. Claim Form duly filled in & signed.2. Original Repair Bills with receipt.

3. Details of Third party Claims.


5. Boiler Inspectorate's report.

Electronic Equipment Insurance Policy

1. Claim Form duly filled in & signed.

Claims management

2. Original Repair Bills with receipt.


4.

5.

SWOT Analysis:

Claims management

Lack of new technologyPoor record managementLow customer retentionSales channels

Lack of new technologyPoor record managementLow customer retentionSales channels

Excellent, very well qualified staff 1500 crore business with health port folio growing with 30%/year. Company has strategic branches all over the IndiaFeatured website with easy accessibility Quick response Customer Satisfaction

Excellent, very well qualified staff 1500 crore business with health port folio growing with 30%/year. Company has strategic branches all over the IndiaFeatured website with easy accessibility Quick response Customer Satisfaction

OPPORTUNITIES

OPPORTUNITIES

STREGNTHSSTREGNTHSWEAKNESSWEAKNESS

THREATSTHREATS

OPP0RTUNITIESOPP0RTUNITIES

ObservationsClaims files must be monitored as they progress. A little time spent thinking clearly right from the beginning will avoid lot of unnecessary and time consuming patch-ups and straightening out later on. Unpleasant decisions conveyed timely with proper justification of the decision is better than procrastination which is bound to create more problems and unpleasant situations.Lot of time / energy / money is spent when claim cases go to Ombudsman / Consumer Forum/ Court. Besides, adverse comment bring bad name, when we are held liable. Insurance companies are invariably at the receiving end. The “watch and wait” attitude must change. There is a need to find out why so many cases go to consumer forum or the ombudsman and what should be done about it.

Conclusion

In the current Indian market scenario, the

products offered by various general insurance companies are more or less the same. The success of the settling the claim comes from its service differentiation.

Claims management

Have our own TPA, which rules over hurdles created due to TPA processing in case of health claims. Within 10 years expanded on

international level which & continues to be the same…

Gives better coverage by charging less premiumproducts are quite practicle

Have our own TPA, which rules over hurdles created due to TPA processing in case of health claims. Within 10 years expanded on

international level which & continues to be the same…

Gives better coverage by charging less premiumproducts are quite practicle

Changes in government provisionsTechnological advancesNew distribution channelsNew insurance and TPA companies

Changes in government provisionsTechnological advancesNew distribution channelsNew insurance and TPA companies

Claims management

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