CLAIMS MANAGEMENT FRAMEWORK

Transcription

1 CLAIMS MANAGEMENT FRAMEWORK 1. Introduction The objectives of this policy are to set out a framework to comply with legislation and with the Claims Management Requirements. Eqstra Financial Services (EFS), as an authorised financial services provider, has a responsibility to conduct itself honestly, with integrity, fairness, dignity and ethically wherever it operates. EFS has to ensure that the customer s rights and obligations, when lodging a claim, is well communicated and that it has a transparent insurance claims process and procedures. EFS must also set up the roles and responsibilities of staff and management and closely align it with the. 2. Objective The must be maintained, operated adequately and effectively and ensure that it: a) is proportionate to the nature, scale and complexity of Eqstra s business and risks; b) is appropriate for the business model, policies, services and policyholders of Eqstra; c) enables claims to be assessed after taking reasonable steps to gather and investigate all relevant and appropriate information and circumstances, with due regard to fair treatment of customers; d) Does not impose unreasonable barriers to claim to customers. It is a requirement of the Management team to take all reasonable steps to ensure that Eqstra has implemented critical policies for effective financial and risk management. Process Claims Recovery Loss Prevention Insurance Management Activities Claims Management, Loss Adjustment and Settlement/Write Off and Salvage 3 rd parties and Insurance Recovery, Mitigation and Extra Operation Services Audit, Review of Process, Costs Assessment and Contract Review Manager Risk Profile, Insurance Procurement and Record Keeping 1

2 3. Claims Handling Allocation of Duties The Operations Manager is responsible within Eqstra to ensure that all claims lodged are treated in line with the framework. The Operations Manager will ensure that adequate resources are allocated to claims handling and that any person dealing with claims are: a) Adequately trained; b) Experienced in claims handling and appropriately qualified; c) Not subjected to a conflict of interest, and; d) Is adequately empowered to make impartial decisions or recommendations. 4. Claims Handling Process The following standards apply regarding insurance claims: A Client must call into the call centre to report an incident; Call centre agent requests all incident related information; A claim is registered electronically on the in-house system; A claim form is generated via the system and sent out to the client/driver to complete and back with a copy of their driver s license. An appropriate service provider is selected to provide Eqstra with an estimation of the costing of the damaged vehicle; o Non-driveable: Tow is administered to the nearest Eqstra affiliated panel beater o Driveable Panel beaters will contact the client to arrange to view and quantify the damages of the vehicle. Upon receipt of two quotes: o Quote value > R An assessor is appointed to review the quotes and supply Eqstra with a report of his findings/damages to the vehicle and an assessed quote. o Quote value < R The most comprehensive quote is selected and approved. The panel beater which was awarded the repair will contact the client and arrange for the vehicle to be brought in for repairs. If the vehicle is uneconomical to repair the following will take place: o An assessor s report is received advising the vehicle is uneconomical to repair 2

3 5. Write off and Salvage Process Upon receipt of the assessor s report, we determine if the vehicle is a write off. The value of the vehicle is determined by the assessor from the Mead and McGrouther book and the level of damage determines the write off code: Code 2 Uneconomical to repair On a code 2 vehicle the client can opt to buy the salvage without deregistration of the vehicle. o The vehicle will be removed from insurance cover until the insured/broker can supply Eqstra with proof that the vehicle has been repaired. This can only be proved by providing an inspection certificate as well as a roadworthy certificate. Code 3 Permanently Unfit for Use On a code 3 vehicle the client can opt to buy the salvage but must advise the insurer what the vehicle will be used for and would need to deregister the vehicle. Eqstra will not be able to add the vehicle back on insurance cover. Code 4 Demolished/Complete Burnt Out On a code 4 vehicle there is no option to buy back the vehicle. 6. A communication is sent via to the insured/manager advising that the vehicle is uneconomical to repair, will be written off and the option to buy back the salvage is given to them (should the insured decline the option to buy back the salvage, our internal salvage process will apply) As part of the communication or interaction above, the client is to confirm that they are aware of the following for us to proceed: a) we are planning to write off the vehicle and that they agree with it; b) what the settlement amount will be and how it was calculated; c) what the impact of the excess will be and the nett settlement amount; d) how the money will be distributed if there is a finance House involved; e) what the situation is if there is a shortfall in the outstanding finance amount; f) option to Buy back the Salvage within the guidelines above. 7. If Insured Disputes the Write off, they will have an opportunity to source their own quote from an outside supplier, however this quote will be scrutinised by our assessor/technical specialist for a final decision. 3

4 8. If the client wishes to buy back the Salvage we must agree on the settlement amount of the write-off and the buy-back percentage (and amount) at this stage, storage fees, upliftment costs, additional repairs, etc will be for the insured s account. 9. If the client agrees to the write-off of the vehicle, the settlement amount, and agrees that they don t want to buy back the salvage, then a salvager is appointed to uplift the vehicle and store at their premises to avoid any storage or release fees until the settlement is concluded. NB at this point the insured cannot request to buy back the salvage. Should they want to buy the vehicle back this transaction will have to be directly with the salvager at their own pricing. 10. Relevant Documents are requested from the insured /manager to process settlement: Vehicle is financed or leased o Settlement letter from the Finance House /Leasing Company. o Copy of the Natis Document Vehicle is owned o Original Natis Document o Copy of the Owners ID o Signed Change of Ownership Document o Completed Client Refund Form o Proof of Bank Details 11. Upon receipt of all relevant documentation, an agreement of loss is drawn up and sent to the relevant parties for acceptance/signature: The Agreement of loss reflects o Sum Insured (Retail Value) o All Applicable Excesses as per the policy o Any deductions (if vehicle was financed/ Insured opted to buy back the salvage) o Total Payable to Insured /Due by Insured 12. Once the agreement of loss is signed and sent back to us, settlement to the finance house /individual is processed: Settlement Made to Finance house 13. A Formal request is sent to the finance house for the original registration /deregistration document for the salvage process to continue. 14. Eqstra is committed to having processes in place to deal with claims in a structured and timely manner: 4

5 The Claims Process Flow 15. Record Keeping, Monitoring and Analysis All claims received, assessed, and finalised will be kept for a minimum period of 5 years: a) The documents are filled physically (hardcopy) were available b) As well as an electronic scanned copy on the internal network drives and the operational system. Trends, risks and remedial actions to review product design and disclosures in line with Treating Customers Fairly principles. 16. Repudiations or disputes Eqstra must communicate the following to the customer: a) The reason for the decision; b) Include the facts that supports the decision; c) That the customer may within a period of not less than 90 days after the date of receipt of the notice make representation to the administrator; d) Have the right to lodge a complaint to the relevant Ombudsman and provide the contract details and time limitation of the Ombudsman. 5

6 17. Complaints Handling Process To ensure a quick and appropriate response to complaints, the following process should be used at all times by all relevant staff: a) Log the date and content of the complaint with the complaints administrator that handles the complaints register. b) If the complaint is logged telephonically make full notes of the complaint and start the complaint resolution process immediately. c) Send the external complaints resolution procedure document to the customer and confirm to the customer in writing that we are attending to the complaint. d) Confirm with the customer the requirement to lodge the complaint in writing, including the following information: Name and contact details of the complainant or complainant s representative (if applicable). Policy or Claims reference number. Full details of the complaint (facts, dates, and supporting documents, etc.) the details of your compliment or complaint (where you satisfied, or what did not meet your expectation). How can we regain the customer s confidence in our service and meet their expectations? If the customer refuses or cannot lodge the complaint in writing, acknowledge receipt of the complaint in writing within 72 hours of receipt (3 working days), and give the customer the name(s) and contact details of the staff responsible for the resolution of the complaint. e) Appoint a staff member responsible for the resolution of the complaint. f) Acknowledge receipt of the complaint in writing within 72 hours of receipt (3 working days) and give the customer the name(s) and contact details of the staff responsible for the resolution of the complaint. g) Investigate the complaint to ascertain whether the complaint is legitimate and/or can be resolved immediately. h) If the complaint can be resolved immediately, take the necessary action and inform the customer accordingly. i) Should additional information be required from the customer, request supporting documentation (if any) that may be necessary to resolve the matter and indicate the expected date of resolution, this must be requested in writing from the customer. 6

7 j) At all times ensure that the customer is kept informed of the process of their complaint/request, whilst it is being attended to. k) If the complaint cannot be resolved immediately, send the customer a written summary of the steps to be taken to resolve the matter and the expected date of resolution. l) If unable to resolve the complaint within a further 3 weeks of the written acknowledgment (6 weeks since complaint logged), notify the customer giving full written reasons as to why the outcome was not favourable, and advise the customer of internal Dispute Resolution Forum. Eqstra as the FSP (FSP 46229), is required to document all complaints related to its insurance business. All complaints must be directed to: Contact Number : address : complaints@eqstrafleet.co.za Please note the Complaints are recorded as per the Regulatory requirements and will prompt you for a follow up to ensure that complaints as per the Act are resolved. 7