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CHAPTER 8
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Definition of Insurance Claim : A claim is the demand that the Insurer should redeem the promise made in the contract. Insurers Role : Satisfying himself that all conditions are fulfilled and requirements have been complied. Settle the claim.
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TYPES OF CLAIMS
a) Maturity Claims : Payable on date of completion of the term of the policy. b) Survival Benefit Claims : Payable on survival of the Life Assured up to a particular date, during the currency of the policy. c) Death claims : Payable on death of the Life Assured. d) Accident & Disability Claims : - Accident claim is payable on death of life assured due to accident. -Disability claim is payable when total and permanent disability occurs as a result of an accident.
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MATURITY CLAIMS
Payment on maturity date, i.e., on completion of contract (term of policy). Amount payable = (Sum Assured+Bonus-outstanding premiums-outstanding loan and loan interest, if any) Advance intimation is sent to the policyholder by them the Insurer (about 90 days in advance) Post dated cheques are issued provided all necessary requirements are received from the Life Assured.
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3. Some claims are payable later than the maturity date or in instalments. Eg: Under LICs Educational Annuity/Marriage Endowment Plan, the sum assured is payable at the end of 10/7/2013 10 selected term either in lumpsum or in 10 half-
-2000 --2000
13,500
-13,500
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DEATH CLAIMS
More complex procedure of settlement as facts relating to death and identities of claimants to be established by the insurer. Intimation of death may be sent to insurer by the nominee, assignee, relatives, employer or agent. Insurer himself can begin action by taking notice of obituary columns or newspaper reports provided identity of deceased is established. Additional requirements from claimants (death certificate, certificate of burial or cremation, legal evidence of title, etc).
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3. the funeral and seen the dead body (to confirm genuineness of the circumstances of death of the policyholder). 4. Statement from Life Assureds employer, showing leave details (Medical certificates collected if leave was availed on sick grounds). 5. Additional requirements in case of unnatural death such as accident, suicide, murder (Panchnama, Police First Information Report & final report, chemical analysers report, post mortem report, Court judgement, if any).
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EARLY DEATH CLAIMS (Contd..) Statement from person who has attended
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SECTION 45
Section 45 of the Insurance Act, 1938 provides that no policy can be called in question after a period of two years from the date of its issue on the ground that any statement in the proposal or a related document was false or inaccurate (making the policy indisputable). This provision is not applicable if the Corporation can prove that misrepresentation or non-disclosure was on a material fact and was fraudulently made and that the policyholder knew at the time that the statement he made was false.
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CLAIM INVESTIGATIONS
Are necessary in early claim cases to prevent fraudulent claims as such payments amount to undue advantage to the claimant at the cost of other policyholders.
Provide sustainable evidence to repudiate a claim. Suspicion, however strong, is not enough.
Provide data to tighten underwriting standards. Highlight agents & regions prone to early claims.
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- x-charge, if any
+ Accident benefit Net claim amount payable
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-10,000 22,800
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Eligibility Conditions : a) b) c) Accident caused by outward, violent and visible means. Death/disability is result of injuries caused by accident. Occurrence of death/disability should be within 180 days of accident.
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Accident Benefit: If death occurs due to an accident then normally additional sum assured is payable besides the death claim. If claim is payable at a later date, then future premiums may be waived.
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DISABILITY BENEFIT
Definition : Disability must be the result of an accident and must be total & permanent and such that there is neither then nor at any time thereafter any work, occupation or profession that the life assured can ever sufficiently do or follow to earn or obtain any wages, compensation or profit. Accidental injuries which independently of all other causes and within 180 days from the happening of such accident, result in irrevocable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrists, or in the amputation of both feet at or above ankles, or in the amputation of one hand at or above the wrist and one foot at or above the ankle, shall be deemed to constitute such disability.
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Benefits Payable : Waiver of future premiums. Additional amount equal to sum assured paid in monthly instalments spread over 10 years. If claim arises before expiry of the above said 10 years, then remaining instalments of disability will be paid alongwith the claim amount.
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CLAIMS CONCESSION
Claims (not always full amount) are paid on lapsed policies, if policy has acquired paid up value before lapsation. LIC pays full claim after deducting outstanding premiums with interest in the following cases : a) At least 3 arises within premium. b) At least 5 arises within premium.
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years premiums are paid and death claim 6 months from the date of first unpaid
years premiums are paid and death claim 12 months from the date of first unpaid
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Full claim is paid where arrangements are made to advance the premiums from surrender value.
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PRESUMPTION OF DEATH
Proof of death is must. Evidence of Death collected in the form of Death Certificate and certificate of burial and cremation. In case of accidents on sea, in air and in natural calamities, dead bodies may not be found. Obtain statement from Competent Authority. Indian Evidence Act provides for presumption of death, if a person has not been seen or heard of for seven years.
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Premium to be paid under the policy till Court decrees presumption of death so that the policy does not lapse during this period.
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OTHER PRECAUTIONS
1. If the Life Assured or claimant is a lunatic, only the guardian appointed by the Court of Law as per Indian Lunacy Act should sign the discharge voucher. If Life Assured or claimant has recovered from mental disorder, insist on medical certificate to that effect.
2.
3.
Orders received from Court are not to be contested by orders are not appropriate, vacated (Eg: Attachment issued under MWP Act).
or other judicial authority the Insurer. However, if the claimant must get it order in case of policy
4.
Claim payments to non-residents are governed by the foreign exchange control regulations.
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6.
7.
IRDA REGULATIONS
In case of death claim, all requirements to be called at one time and not in piecemeal. Decision of claim to be taken within 30 days of receipt of requirements from the claimant.
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