قالب وردپرس درنا توس
Home / Insurance / Claim to bid | Zalma on insurance

Claim to bid | Zalma on insurance



Watch the full video at https://rumble.com/v1qrtao-claims-commandments.html and at https://youtu.be/V012MEVobJo

Insurance claims are a service activity. The injured party – regardless of whether he acts for the insurer or the insured – provides a service to the insured and the insurer. Communication is essential to providing the service promised by the policy.

In some states, such as California, communication is required by regulation:

Each insurer shall disclose to a first-party claimant or beneficiary any benefits, coverage, time limits or other provisions of an insurance policy issued by that insurer that may be applicable to the claim presented by the claimant. When additional benefits may reasonably be payable under an insured’s policy upon receipt of additional proof of damages, the insurer shall promptly notify the insured of that fact and cooperate with and assist the insured in determining the extent of the insurer’s additional liability. [10 CCR 2695.4 (a)]

This means that the first written contact with an insured in a first party property claim should inform the insured of any benefits, coverage, time limits or other provisions of any policy issued by that insurer that may apply to the first party claim. party insured.

When an indemnified party receives any communication from an insured, third-party claimant, or a representative of the insured or injured party regarding a claim that reasonably suggests that a response is expected, he or she should promptly upon receipt of the communication provide the claimant with a complete response based on facts then known by the person indemnified. Some rules allow the injured party up to 20 days to respond. Good complaint handling requires an immediate response. If the response is verbal rather than written, it must be noted in the claimant’s file or log.

After receiving notification of the claim, each policyholder should immediately do the following:

  • Acknowledge receipt of such notice to the injured party or the insured.
  • If the acknowledgment is not in writing, a note of the acknowledgment must be made in the insurer’s claim report and dated.
  • Provide the injured party or the insured with necessary forms, instructions and reasonable assistance, including but not limited to specifying the information the claimant must provide to prove the claim;
  • Initiate a necessary investigation of the claim.

The investigation must be “real”. The claimant or investigator must actually contact the insured, the claimant, the witnesses and begin gathering the documents needed to complete the claim investigation. Investigation and must begin immediately after receipt of notification of complaint.

Simply reading a policy statement and reporting a complaint is not the start of an investigation or an investigation at all.

Upon receiving proof of claim, each insured should immediately accept or deny the claim, in whole or in part. Proof of Claim is not the proof of loss required as a condition of insurance. A proof of claim is when the insured provides the insurer with sufficient information to enable the insurer to determine part or all of the insured’s claim. The amounts that are accepted or rejected must be clearly documented in the claim document unless the claim has been rejected in its entirety.

Some states allow up to 40 calendar days to respond to a proof of claim. If more time is required to determine whether a claim should be accepted and/or rejected in whole or in part, the claimant must notify the injured party or the insured in writing of the need for additional time.

The written notice should state any additional information the policyholder needs to make a decision. The written notice should state any continuing reasons for the insurer’s inability to decide. Thereafter, the written notice of additional time to complete an investigation should be provided to the insured at least every thirty calendar days until a decision is made.

If the determination cannot be made until some future event occurs, the indemnifier should comply with this continuing notice requirement by informing the injured party and/or the insured of the situation and providing an estimate of when the determination may be made.

Effective logbook systems are essential to professional claims management, otherwise regulations will be regularly breached.

Each Indemnitee must conduct and diligently pursue a thorough, fair and objective investigation and should not persist in seeking information not reasonably required or essential to the resolution of a Claim Dispute.

The replacement person’s obligation is not limited to communication with the insured or injured party.

In addition, the claimant and the insurer have a duty to communicate with the state, police authorities or prosecutors if they suspect that an insured or an injured party is attempting to defraud.

In California, and most states, such communications are absolutely immune from suit. California Civil Code Section 47(b) provides a privilege barring a civil action for damages for communications made “[i]n any (1) legislative proceeding, (2) judicial proceeding, (3) in any other official proceeding permitted by law, or (4) in the commencement or course of any other proceeding permitted by law and which may be tried pursuant with [statutes governing writs of mandate]”, with certain statutory exceptions.

The privilege established by this subdivision is often referred to as an “absolute” privilege, and it precludes all causes of action except a claim for malicious prosecution. “The absolute privilege of section 47 represents a value judgment that the facilitation of the ‘ultimate freedom of communication between citizens and public authorities whose responsibility it is to investigate and remedy wrongs’ is more important than ‘individual injuries which may befall a defamed individual.'” (See Imig v. Ferrar (1977) 70 Cal. App. 3d 48, 55-56 [138 Cal. Rptr. 540].)”

To satisfy Proposition III, the indemnitee must communicate promptly and frequently with the insured, the injured party, and the insured (if a third party asserts) and counsel for each. By doing so, the claimant establishes a relationship with the insured and/or the injured party and will make resolution of the claim easier.

No claim may ever misrepresent or conceal benefits, insurance, time limits or other provisions of the insurance from the insured or the injured party.

(c) 2022 Barry Zalma & ClaimSchool, Inc.

Barry Zalma, Esq., CFE, now limits his practice to serving as an insurance consultant specializing in insurance coverage, insurance claims management, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He practiced law in California for more than 44 years as an insurance coverage and claims attorney and more than 54 years in the insurance industry. He can be reached at http://www.zalma.com and zalma@zalma.com. Subscribe and receive videos limited to Excellence in Claims Handling subscribers at locals.com https://zalmaoninsurance.locals.com/subscribe.Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome.

Write to Mr. Zalma at zalma@zalma.com; http://www.zalma.com; http://zalma.com/blog; daily articles are published on https://zalma.substack.com. Go to the Zalma On Insurance podcast at https://anchor.fm/barry-zalma; Follow Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos on Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to Insurance Claims Library – https://zalma.com/blog/insurance-claims-library




Source link