Contract Construction Management-130420145229-phpapp02

8/9/2019 Contract Construction Management-130420145229-phpapp02

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PRESENTED BY:

Kapil Dev SharmaKunal Dhawan

Naved Sami

Pooja Babber

Vishal Sharma


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Essential Elements o !nsuran"e

#on"ept o #laim

$mount pa%able T%pes o #laims

Pro"essin& o !nsuran"e #laim

'uidelines

Disputes in !nsuran"e #laim

Reje"tion o #laim

Summar%


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#on"ept o !nsurable !nterest

Do"trine o 'ood (aith

Pro)imate #ause


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#laim is a ri&ht o insured to re"eive the amount se"uredunder the poli"% o insuran"e "ontra"t promised b%!nsurer

!nsuran"e #laim is the re*uest o the insured poli"%holder+benei"iar% rom the insurer+insuran"e issuin&"ompan% or inan"ial reimbursement whenever he+shesuers a loss o the insured propert%+lie+health+et"

!nsurer, settle the "laim ater satis%in& himsel that allthe "onditions and re*uirements or settlement o "laimhave been "ompiled with


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Should be done in a""ordan"e with the spe"ii"ationso the insuran"e poli"%+"ontra"t

The amount insured or a"e value o poli"%

Bonus i de"lared b% "ompan%

Share o proit in "ase o parti"ipation poli"%

Surrender value i poli"% lapsed


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Pa%able as per the terms o "ontra"t, at the end o the term !nsurers inorm the poli"%holder well in advan"e about the

maturit% date

!nsurers send the orm o dis"har&e whi"h is dul% si&ned- andreturned with,

a. /ri&inal Poli"% do"ument

b. proo o a&e, to prove the identit%

". Do"ument o assi&nment, i e)e"uted on a separatestamped paper

'ross amount in"ludes basi" sum assured- bonus et" Dedu"tions in"lude loan amount- unpaid premium et"0

#ir"umstan"es li1e settlin& the "laim on the basis oindemnit% bond re*uire more "aution 2in "ase ori&inal poli"%is not ound.


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!ntimation o death b% a proper person and proo odeath

A. Premature/early claim: insured dies within 3 years oftaking out of policy

a. statement rom the last medi"al attendant &ivin& detailso last illness and treatment

b. Statement rom the hospital

". Statement rom the emplo%er

B. Other claim : insured dies after 3 years of taking out ofpolicy

a. Poli"% number and Name o lie assuredb. Date and #ause o death

". #laimants relationship

d. Death "ertii"ate

e. Deeds o assi&nment


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C. In case of unnatural death: accident suicide orunknown cause etc

a0 Poli"e in*uest report

b0 Pan"hanama

"0 Post mortem report

d0 #hemi"al e)amination report

!. "nder the Indian #$idence Act a person is presumed to%e dead if he is disappeared for & years

3pon the death o the lie insured the amount is pa%ableto the nominee &iven in the proposal orm


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Some poli"ies entitled or the survival beneit beorethe e)pir% o the ull term o the poli"%

Settlement is easier than maturit% "laim

!nsurer sends advan"e intimation and the dis"har&evou"her whi"h is returned with ne"essar% do"uments

a. Proo o identit%

b. /ri&inal poli"%". Do"ument o assi&nment


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4. The poli"% holder or the benei"iar% "alls up the insurer

"laimin& the insuran"e as1in& about all the minute detailso the pro"ess o "laimin& the same alon& with thedo"uments re*uired

5. The insuran"e "ompan% as1s or the details o the loss andthe relevant do"uments in support o the #laim

6. $ noti"e has to be issued b% the poli"% holder or "laimin&the same with utmost ur&en"% mentionin& all the possibledetails 2namel%- name o the poli"% holder- names o thepersons asso"iated with the a""ident- witness parti"ulars-their addresses- et".0


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7. The insuran"e "ompan% would ma1e all the possible *ueriesand inspe"tions b% the "ompan% representatives or "onsultants

8. The% have the ri&ht to inspe"t all the relevant propertiesrelated with the loss alon& with poli"e verii"ations anddetermination o the poli"% holder9s liabilit% stru"ture

. The pro"essin& period is mentioned in the "ontra"t do"ument-whi"h is the appro)imate time re*uired or verii"ation o the&enuineness o the !nsuran"e #laim

;. /n a&reement o "laim amount between the insured and the

insurer- the "laim is settled

#laim orm


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$s per !RD$- !nsuran"e "ompan% is re*uired to settle a "laim within 6a. Survival up to end o the poli"% term, maturit% "laim

b. Survival up to a spe"iied period durin& the term >survival beneits "laim

". Death o the lie assured durin& the term > death"laims

!nsuran"e "laim mana&ement is a "ore issue or theprote"tion o insuran"e poli"%holders


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#ompleted proposal orm pla%s an important role asit ae"ts the "laims under poli"%

!t has been observed that all the !nsuran"e #laimsare not &enuine and are raudulent in nature0 So-

ever% !nsuran"e #laim is needed to be pro"essed b%the insurer beore approval in order to avoid

insuran"e raud

Need or enhan"ed ei"ien"%- transparen"% anddis"losure o inormation to poli"%holders durin& the

"laim mana&ement pro"ess


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?r0 Devinderpal Sin&h- a resident o @amalpur- had ta1en a ?edi"laimpoli"% rom the "ompan% or his 4


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The "ompan% urther stated that Dr Tarsem al 'upta who wasreerred the "ase or the medi"al opinion- said Raja was suerin&rom pre,e)istin& disease at the time o ta1in& the insuran"e poli"%

and as the "laim ell within the exclusion clause No. 401 o thepoli"%0 The "ompan% maintained that the "laim was ri&htl%repudiated

The orum observed- !t appears as i the ather o Raja had1nowled&e o the disease and as su"h he too1 the poli"% to meet the

e)penses o the treatment0 The orum stated that the disease waspre-existingandwas not covered under the policy0 The orumurther added that the "ompan% had intimated the "omplainant thatthe "laim lod&ed was "onsidered as 9no "laim9 as per the rules o thepoli"%0 The orum held that there was a "lear dei"ien"% on the part othe "ompan% or not intimatin& the "omplainant

The Distri"t #onsumer Disputes and Redressal (orum in udhianadire"ted National !nsuran"e #ompan% to pa% Rs 8-


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