Claims Management
Claims process
Claims management covers notification, registration, validation, investigation, assessment, settlement and recovery. Know the importance of policy conditions such as notification, cooperation and proof of loss. Understand how the claims handler verifies cover, checks exclusions and conditions, assesses quantum, and manages third-party providers such as loss adjusters and investigators.
Fraud and leakage
Claims fraud and leakage are major cost drivers. Candidates must understand indicators of fraud, the role of data analytics, and the importance of a consistent fraud strategy. Leakage includes overpayment, duplicate payments and unnecessary costs. Good claims governance includes authority limits, segregation of duties and audit trails.
Reserving and reporting
Claims reserves must be adequate and consistent. Know the difference between case reserves and incurred but not reported (IBNR) reserves, and how claims data feeds reserving and pricing. Subrogation and salvage recoveries reduce net claims cost.
Traps in questions
A frequent trap is treating a claim as payable merely because a loss occurred; cover, conditions and exclusions must be satisfied. Another is confusing loss adjuster and loss assessor roles. Questions may also test whether a claim can be denied for late notification; the effect depends on prejudice to the insurer.
Worked example
A claim is notified six months late. The handler must assess whether the delay prejudiced the insurer's ability to investigate. If prejudice is shown, cover may be affected; if not, the claim may still be paid. Apply the policy wording and legal test.
Exam technique
Structure answers around cover, conditions, quantum and recovery.