Complex claims, appeals and recoveries

Large and complicated claims need more than an amount and a decision. This guide covers triage and service deadlines, several people and heads of claim, the settlement calculation, partial and ex-gratia decisions, appeals, recoveries, court cases and catastrophe events.

Triage and assignment

Every new claim is triaged as it arrives, however it arrives (staff, portal, provider):

• severity from the amount and any injuries (low, medium, high, critical),
• complexity from third parties, injuries and court cases (simple, standard, complex),
• urgency: serious injuries or a large hospital bill.

The claim is then given to the claims handler with the fewest open claims; high and critical claims go to someone who may approve. Possible duplicates (same policy, date, kind of loss and amount) and claims from the same incident (same date and place) are linked on the claim.

Service deadlines

Each claim has three deadlines: acknowledge (24 hours, 4 for urgent claims), decide (15 days, 30 for complex claims) and pay once approved (7 days). The Past deadline tab lists the claims that missed one. The daily run tells the claims managers, and a day later the main account. Acknowledge on a claim meets the first deadline. The claim shows how long it has been open.

People involved and exposures

People involved records third parties, injured people, drivers and witnesses, with their vehicle and insurer and any injury. Injuries feed the triage.

Exposures split a claim into heads: own damage, the other car, a bodily injury. Each has its own amount claimed, reserve and decision; the claim's totals follow. When paying, choose the exposure the payment is for.

The settlement calculator

Settlement calculator works the figure out step by step: the assessed loss, less depreciation (betterment) and any salvage the insured keeps, reduced in proportion when the property was underinsured (insured for 80% of its value pays 80%), less the deductible, capped at the limit. Save it, and tick when the claimant has agreed it. The calculation shows on the claim and the approval form reminds you of it.

Approving in full, in part, or ex gratia

Approve settlement asks for the decision: in full, in part (say why: the customer is told) or ex gratia, a goodwill payment outside the cover. Ex gratia can be agreed on a rejected claim; its payments are marked as ex gratia in the records.

Appeals

When a claimant disputes a decision, Appeals > Record an appeal logs the grounds; the answer is due in 30 days and the claims managers are told. Decide: upheld or partly upheld reopens the claim with the revised amount approved; dismissed leaves it as it was. The claimant is emailed the reasons.

Recoveries

Recoveries tracks money coming back: from the party at fault or their insurer (subrogation), from the sale of the wreck (salvage), or a deductible owed. Record each amount as it arrives; the claim shows what was recovered and the net paid.

Litigation

Litigation holds court cases: the court and reference, our side, the law firm and lawyer, the amount claimed and a legal reserve. Log a hearing (with the next date), a filing or a cost; the costs add up on the claim. Close case with the outcome.

Catastrophe events

Claims > Catastrophe events records a storm, a flood or an earthquake with its dates and region (a catastrophe zone code, or a region or place name). New claims in those dates and that region are coded to it as they arrive; Code existing claims catches the ones registered before. Each event shows its claims, reserves and payments.