Claims handling, documentation and customer service
Domain 4 tests the claim journey end to end: prompt notification, correct documentation, assessment, settlement from the risk fund, and the service and complaint standards that apply when a participant is dissatisfied.
The claim process
- Intimation and registration: date-stamp the notice, confirm the scheme is in force and the contribution paid, and identify the cover, excess and conditions.
- Coverage review: peril covered, exclusion or warranty breached, insurable interest, adequacy of the sum covered (average clause for property).
- Surveyor: for losses above the prescribed threshold an SECP-approved surveyor assesses and reports; an agent's opinion cannot replace that report.
- Decision: settle with the calculation shown, or repudiate in writing citing the specific clause relied on; payment comes from the participants' risk fund.
- Recovery: salvage realisation and subrogation against a negligent third party, with recoveries credited back to the risk fund.
Documentation typically required
Claim form, policy or certificate and schedule, participant ID, evidence of loss (FIR for theft or accident, fire report), repair estimates and invoices, surveyor report, discharge voucher and a subrogation letter where recovery is possible.
Takaful-specific point
Claims are met from the participants' risk fund, not the shareholders' fund. If the fund is short, shareholders advance qard-e-hasan, repaid from future surplus; the wakala fee is not the source of claim payment.
Worked example
A motor own-damage claim with a repair estimate of Rs 250,000. The scheme applies a standard excess of Rs 10,000 and depreciation of Rs 15,000 on plastic and rubber parts under its claim policy. Payable = 250,000 − 10,000 − 15,000 = Rs 225,000, provided the vehicle was covered, the driver licensed and no exclusion applied. The agent explains each deduction before the participant signs the discharge.
Marks that are commonly lost
- Advising a participant to inflate a claim - that is fraud, not service.
- Promising a settlement figure before the surveyor reports.
- Ignoring a third-party liability claim because the participant held only own-damage cover.
- Not telling the participant about the operator's grievance process and the Federal Insurance Ombudsman.