PSG Insurance Claims Procedures PDF

3. Payment Process 3.1 Request and Approval Claim handlers request payments for clients and finance houses. Payment team requests payments to service providers. Request and approval cannot be executed by the same individual. 3.2 Accountability Staff recommending and authorising payments are accounta...

3. Payment Process 3.1 Request and Approval Claim handlers request payments for clients and finance houses. Payment team requests payments to service providers. Request and approval cannot be executed by the same individual. 3.2 Accountability Staff recommending and authorising payments are accountable for their decisions within their mandate. 3.3 Responsibility Authorising manager ensures proper documentation supports the payment. Claims exceeding the mandate must be referred to the Insurer. 3.4 Release of Payments PSG Finance Department releases payments, maintaining separation between requesters and fund disbursement. 3.5 Verification Compare requested amount with approved claim cost to ensure accuracy. 3.6 Invoice Information Invoices must comply with VAT regulations and include comprehensive details. 3.7 Preventing Duplicates Check previous payments to avoid duplicates. 3.8 Account Details Verification Verify account details, especially for new service providers or discrepancies. Confirm bank details telephonically, not via email. 3.9 Confirmation Protocols Confirm information received via email by contacting claimants directly. 3.10 Controlled Handling of Banking Details Banking details updated or captured by Claims Support Officer with confirmation from a Team Leader or Manager. Audit trail tracks changes to banking details. 3.11 Checklists for Confirmation Motor Salvage and Stolen Vehicle Claims These procedures ensure thorough investigation, proper documentation, and efficient handling of motor salvage and stolen vehicle claims, following insurer-approved processes and guidelines. 1. Motor Salvage 1.1 Disposal of Motor Salvage Responsibility: PSG handles the disposal of motor salvage through Insurer-approved salvage agents. Procedure: All vehicles owned by the Insurer after claims settlements must be sold to authorised salvage agents. Refer motor salvage outside the Insurer’s agreement with the salvage agent to the Insurer. Obtain Insurer approval for salvage retention, which affects settlement calculations and policy endorsements. 1.2 Ownership and Buyback Policy: The insured cannot own the salvage after claim settlement. The Buyback option is available only from the salvage agent. The Insurer is not entitled to the salvage of vehicles insured for less than the market/retail value. 1.3 Handling Salvage Proceeds Procedure: If the insured amount plus salvage value is less than the market/retail value, the insured keeps the salvage. If the insured amount plus salvage value exceeds the market/retail value, the Insurer gets the excess proceeds. 1.4 Uneconomical to Repair Criteria: Vehicles are uneconomical to repair if repair costs exceed a certain percentage of the pre-accident value. Factors include model, type, make, year, and damage type. 1.5 Vehicle Valuation Procedure: Determine the policy basis (market value, replacement value, agreed value, retail value, or trade value). Use the Transunion Auto Dealer’s Guide to determine the vehicle value at the date of loss, adjusting for old damages and non-standard accessories. For vehicles not listed in the Guide, obtain values from the local used vehicle market and use the average of at least three values. 1.6 Documentation for Write-Offs Requirements: Obtain original registration documents for vehicles deemed uneconomical to repair. Deregister vehicles classified as write-offs according to the correct code and NATIS requirements. Claims for written-off or stolen vehicles cannot be settled without the original documentation, except for vehicles under a finance agreement, where a provisional copy of the title from the financial institution will suffice. 1.7 Stock Management Procedure: Dealer stock all motor salvage, write-offs, and stolen vehicles in the name of the Insurer or the Insurer-approved salvage agent. Maintain a Stock in Bond register for all motor salvage. Allocate salvage income in the operational system upon receipt. 2. Stolen Motor Vehicles 2.1 Not Recovered 2.1.1 Unicode System Procedure: Capture details of all stolen vehicles not recovered on the Unicode system by the PSG Insure Short- term Administration Total Loss team. The Unicode system links vehicle theft claims to the South African Police Services (SAPS) mainframe, increasing recovery rates. 2.1.2 Investigation Protocol Procedure: Investigate stolen vehicles according to the agreement with insurers to validate the claim. 2.1.3 Deregistration Process Procedure: The client or Financial Institution must deregister the stolen vehicle. Payment requires the original deregistration document and other necessary items. 2.1.4 Required Documentation Requirements: Provide proof of vehicle extras, security devices, SAP 21 document, two signed change of ownership forms, settlement letter, and all keys for claim settlement. 2.1.5 Corrective Underwriting Procedure: Instruct the Underwriting department to remove the vehicle from cover. 2.2 Recovered 2.2.1 Documentation and Keys Procedure: Send all stolen/hijacked vehicle documentation and keys to the Insurer or Insurer-appointed service provider. 2.2.2 Handling Recovered Vehicles Procedure: Hand over recovered vehicles after claim settlement to the Insurer or Insurer-appointed service provider. Sell recovered vehicles by tender, auction, or contract through the Insurer-approved salvage agent. Hand over recovered vehicles before settlement that are written off to the salvage agent. Repair and return recovered vehicles before settlement that are undamaged or repairable to the insured. Settle stolen vehicle claims only once the original documentation and keys are in possession. PSG Insure Short-term Administration must hand all vehicles to the salvage agent and cannot sell vehicles themselves. Deregister all stolen vehicles according to the correct code. Keep a register of all stolen vehicles. PSG employees cannot buy a stolen recovered vehicle unless it is their own vehicle insured with the relevant insurer, and they must bid for it at an auction. Title: Third-Party Claims and Recoveries 1. Third-Party Claims 1.1 Definition Third-Party Claims: Claims made by someone (the third party) against the insured for damages or losses caused by the insured’s actions or negligence. 1.2 Filing a Third-Party Claim Procedure: The third party can file a claim against the insured’s insurance policy for compensation. Third-party liability coverage protects the insured by covering legal expenses, bodily injury, property damage, and other related costs. 1.3 Investigation and Settlement Procedure: The insurance company investigates the incident to determine liability. The insurer negotiates or settles the claim with the third party. The insurer covers legal defence costs and any settlements or judgments up to the policy limits if the claim is valid and the insured is found responsible. 1.4 Subrogation Definition: Subrogation allows the insurer to seek reimbursement from the party at fault after paying a claim to their insured. Procedure: The insurer can pursue reimbursement from the responsible third party. This process helps insurers recover costs and maintain fairness. 1.5 Client Responsibilities Procedure: The client must initiate the claim and should not negotiate directly with the third party. The third party or their insurer must provide necessary documents, including: ID document Driver’s license Letter of demand Repair quotations Vehicle registration document Non-claim letter from their insurer, if applicable Direct all third-party claims to the insurers or their agents for processing. Redirect any third-party contact to the insurers or their representatives. 1.6 Recording Payments Procedure: Record all payments made to a third party accurately in the operational system as third-party payments. Ensure transparency and proper record-keeping in the claims handling process. 2. Recoveries from Third Parties 2.1 Definition Recovery: The process by which an insurance company seeks to recoup costs or payments made for a loss caused by a third party. 2.2 How It Works Procedure: If an insurance company pays for a loss caused by another person, they can pursue recovery from the at-fault party. For example, if your car is damaged by another driver and your insurance pays for repairs, your insurer can seek reimbursement from the at-fault driver. 2.3 Recovery Process Steps: Investigation: Assess the loss and identify the liable third party. Legal Action: Initiate legal proceedings or negotiations to recover costs from the responsible party or their insurer. Documentation: Provide evidence of the loss, payments made, and the third party’s liability. Negotiation or Settlement: Discuss with the third party or their insurer to agree on reimbursement. 2.4 Importance of Recovery Purpose: Recovery helps insurance companies minimize their financial losses by holding the responsible party accountable. It ensures fairness and prevents the insurer from bearing the entire financial burden for a loss caused by someone else. Title: Treating Customers Fairly (TCF), Protection of Personal Information Act (POPIA), and Policyholder Protection Rules (PPRs) 1. Treating Customers Fairly (TCF) 1.1 Definition Treating Customers Fairly (TCF): A principle ensuring fair treatment of customers throughout their interaction with insurance providers. 1.2 Implementation of TCF 1.2.1 Clear and Transparent Information Provide clear, jargon-free information about insurance products, terms, and conditions. Ensure policies and documents are written in plain language. 1.2.2 Suitability of Products Offer insurance products that are suitable for customers’ needs and circumstances. Recommend products that align with customers’ requirements and risk profiles. 1.2.3 Fair Sales and Marketing Practices Avoid aggressive or misleading sales tactics. Present products and services honestly without pressuring customers into unnecessary coverage. 1.2.4 Customer Education Provide educational resources and advice to help customers understand insurance concepts, coverage options, and risk management. 1.2.5 Transparency in Pricing Clearly disclose costs, fees, premiums, and any other charges associated with insurance products. Ensure customers are aware of what they are paying for and any potential pricing changes. 1.2.6 Handling of Claims Ensure a fair and efficient claims process, handling claims promptly, fairly, and transparently. 1.2.7 Complaints Handling Have a robust complaints resolution process in place. Handle customer complaints fairly, investigate thoroughly, and provide timely resolutions. 1.2.8 Continuous Improvement Regularly review and improve practices based on customer feedback, complaints, and industry developments. 1.2.9 Regulatory Compliance Adhere to regulatory standards and guidelines to protect consumers’ interests and rights. 1.3 Objective of TCF Ensure customers are treated fairly at all stages of their interaction with insurance providers. Build trust, transparency, and accountability in the insurance industry while prioritizing customers’ best interests. 2. Protection of Personal Information Act (POPIA) 2.1 Definition POPIA: A South African law regulating how insurers handle customers’ personal information. 2.2 Key Aspects of POPIA 2.2.1 Protection of Personal Information Define and regulate the processing of personal information. Collect, store, and use customers’ personal information lawfully, transparently, and for legitimate purposes. 2.2.2 Consent and Processing of Information Obtain explicit consent from customers before collecting and processing their personal data. Specify the purpose for which the information will be used. Collect and process only necessary information for legitimate business purposes. 2.2.3 Data Security and Integrity Maintain appropriate security measures to protect personal information from unauthorized access, loss, or theft. Ensure the accuracy and integrity of personal data. 2.2.4 Data Breach Notifications Report data breaches or unauthorized access to personal information to relevant authorities and affected individuals promptly. 2.2.5 Individual Rights Grant individuals rights to access, correct, and request deletion of their personal information under specific circumstances. 2.2.6 Compliance and Accountability Implement policies, procedures, and controls to manage personal information. Demonstrate compliance with POPIA and face penalties for non-compliance. 3. Policyholder Protection Rules (PPRs) 3.1 Definition Policyholder Protection Rules (PPRs): Regulations designed to safeguard the interests of policyholders, enforced by the Financial Sector Conduct Authority (FSCA). 3.2 Key Aspects of PPRs 3.2.1 Disclosure and Transparency Provide clear and comprehensible information about insurance products, terms, conditions, and costs. Ensure policyholders can make informed decisions. 3.2.2 Suitability of Advice and Products Ensure insurance products recommended or sold are suitable for policyholders’ needs, financial circumstances, and risk profiles. Provide advice that aligns with the best interests of the policyholder. 3.2.3 Fairness in Sales Practices Avoid unfair, misleading, or deceptive sales practices. Do not pressure policyholders into purchasing unsuitable products. 3.2.4 Claims Handling and Settlement Handle insurance claims fairly and promptly. Process claims efficiently, fairly assess claims, and settle valid claims quickly. Provide transparent explanations regarding claim decisions. 3.2.5 Handling of Complaints Establish effective mechanisms for handling and resolving policyholders’ complaints fairly and promptly. Maintain proper records of complaints and their resolution processes. 3.2.6 Continuous Monitoring and Review Continuously monitor and review practices to ensure compliance with PPRs. The FSCA oversees and enforces these rules. 3.3 Objective of PPRs Uphold fairness, transparency, and integrity in the insurance industry. Foster trust between insurers and policyholders while protecting policyholders’ interests and rights. These procedures ensure that customers are treated fairly, their personal information is protected, and their rights as policyholders are upheld. Managing Outstanding Claims 1. Regular Review and Analysis Regularly review outstanding claims to check their status. Analyze how long claims have been open, identify any delays, and categorize claims by priority or complexity. Review daily, weekly, and monthly claims reports to ensure timely assessments, accurate estimates, and relevant status updates. 2. Performance Metrics and Reporting Set and maintain key performance indicators (KPIs) to measure how well outstanding claims are managed. Manage the claim handlers’ workflow dashboard to ensure the Service Level Agreement (SLA) with clients is met. This includes daily monitoring of dashboards when claim handlers are unavailable and reassigning open issues during planned leave or long-term absence. Generate regular reports on claim status, aging analysis, resolution rates, and any challenges faced. 3. Documentation and Record-Keeping Keep thorough documentation for each outstanding claim, including correspondence, notes, investigation reports, and updates. Ensure documents are accurately named and records are up-to-date for easy access. 4. Assign Responsibility and Accountability Clearly define roles, responsibilities, and timelines for follow-up actions and resolution. Ensure checklists are completed and attached to all claims to confirm their verification and validity. 5. Communication and Follow-up Regularly communicate with claims handlers, adjusters, or relevant stakeholders to follow up on the progress of outstanding claims. Ensure timely, professional, and clear communication with claimants regarding updates, requirements, or additional information needed. 6. Escalation Protocols Implement procedures for escalating claims that face delays or need extra attention. Define clear paths for escalating unresolved claims to higher management or insurers if necessary. 7. Compliance and Regulatory Adherence Ensure compliance with industry regulations and internal policies when handling outstanding claims. Stay updated on regulatory requirements that might impact the resolution process. 8. Continuous Improvement Review and refine the claims management process based on lessons learned from managing outstanding claims. Identify, report, and implement changes or improvements to enhance efficiency and customer satisfaction. Managing Staff 1. Staff Leave, Attendance, and Availability Ensure compliance with company policies regarding working hours, breaks, and leave entitlement. Ensure team members clock in and out while working in the office. Track and manage availability on the phones, in the office, or while working remotely. Have contingency plans for managing unexpected leave or changes in availability. Inform the Claims Support Officer of any absenteeism for reporting to the switchboard. Ensure out-of-office messages are set up on unavailable staff members’ personal email addresses. 2. Training and Development Identify areas where employees excel and provide positive reinforcement. Pinpoint areas for improvement and training needs in terms of products, processes, and systems. Prepare monthly reports on employees’ performance and discuss discrepancies and areas of concern with recommendations for improvement. 3. Telephone Call Monitoring Ensure team members are trained to manage phone calls professionally and within guidelines. Perform monthly telephone audits on a sample basis to assess and improve the quality of interactions between employees and customers. 4. Performance Evaluation Discussions Conduct performance evaluation discussions to assess performance, discuss accomplishments, identify areas for improvement, and set future goals. Provide specific and constructive feedback on performance. Highlight achievements and discuss performance issues or areas for improvement using examples. Set SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals for the upcoming period. Discuss career development goals and align them with the employee’s aspirations and the organization’s objectives. Consider training opportunities, mentorship, or additional responsibilities to enhance skills and performance. Schedule monthly one-on-one sessions with employees to track progress on goals and provide constant feedback. Reporting 1. Importance of Reporting Reporting by the Claims Management team ensures efficient and effective operations and enables informed decision-making and continuous improvement in claims management practices and staff performance. 2. Key Metrics Number of claims received, processed, and settled within specific time frames. Average turnaround times, SLA breaches, and reworks as indicators of operational efficiency. Accuracy and quality of claims processed to identify errors, trends, and areas for improvement. Consider reworks, rejection overturns, complaints, customer satisfaction scores, and risks captured in the ORR register. Telephone statistics: availability, number of calls received, attended, and dropped. Outcome of telephone audits. Attendance, availability, and identified trends. Challenges or incidents impacting service delivery and/or performance for the specified period. Responsibilities of a Claim Handler When Planning Leave 1. Notify Your Supervisor Inform your supervisor or manager about your planned leave well in advance. Provide details of open claims and any important deadlines or actions required. 2. Claim Statuses, Activities, Estimates, and Documentation Ensure the status of open claims reflects the actual status on Jira, Tial, or SKI. Keep claim activities on Tial or SKI detailed, accurate, and up-to-date. Ensure comments on JIRA are detailed, accurate, and up-to-date. Ensure estimates on Tial or SKI reflect the actual claims cost. Attach and properly name supporting documents on Tial, SKI, and SPM. 3. Out-of-Office Notifications Set up an out-of-office auto-reply on your email. Include the dates you will be on leave and contact details of your team leader or manager. Quality Assurance Officer 1. Role Ensure constant improvement of service delivery in the Claims Process by assessing accuracy, efficiency, and effectiveness. Identify gaps, report trends, and training needs, and recommend possible mitigating initiatives. 2. Tracking Progress on Claims Claims staff must record all actions with comprehensive, legible notes on the operating system. All claim descriptions and notes must be made in English as the official business language. Claims Documentation 1. Attaching Claims Documentation Attach all claims documents to the operating system by sending them to: SKI: [email protected] Tial: [email protected] 2. Uploading and Renaming Documents Claims consultants must upload and rename documents throughout the claims process to ensure completeness and a proper audit trail. Select the appropriate document type on Tial when uploading. Mark documents as confidential if they contain sensitive information. Communication with Clients 1. Keeping Clients Informed Keep clients updated on the progress of their claims. Inform clients of any delays that might impact the finalization of their claims. 2. Automated Emails Automated emails are triggered at various points in the claims process, so it’s important to keep claim statuses updated and relevant. 3. Tial Automated Emails Registration Authorization of Repairs Automated emails can be viewed under the policy attachments on Tial. 4. JIRA Automated Emails Assessor Appointed Report Received Authorization of Repairs Settlement Decision – Replace Settlement Decision – Cash Awaiting Approval of AOL from Insurer Request for AOL to be Signed Payment Made and Claim Closed Referral for Processing Referral for Sign-off Rejection Automated emails can be viewed on the History and Comments tabs in JIRA. Disclosure of Claims Information 1. Restrictions on Disclosure Do not disclose claims information such as telephone recordings, legal opinions, inter-office correspondence, replacement invoices, etc., to advisers, third parties, or clients without the Insurer’s consent. The only exception is documents originally provided by clients and/or advisers in support of a claim (e.g., claims form, proof of purchases). 2. External Parties Do not disclose claims documentation and inter-office correspondence to external parties like external assessors, public adjusters, attorneys, etc., without the Insurer’s consent, except for reinsurers, co-insurers, and external service providers appointed by the Insurer on a claim. Complaints Process 1. Receiving Complaints Claims complaints are received in a central Complaints mailbox from various sources: Clients Advisers Service Providers and Suppliers Insurers Social Media HelloPeter Ombudsman 2. Handling Complaints Follow the PSG Complaints Policy. A dedicated staff member will handle all claim-related complaints. Acknowledge the complaint in writing within five business days and provide the complainant with the contact details of the responsible PSG staff member. Register the complaint in the Complaints register. Investigate the complaint to identify and address the root cause. Report repetitive or serious complaints about external service providers to the Insurers. Involve PSG Human Resources in complaints related to misconduct by claims staff members. Log complaints in the ORR register if processes were not followed or if there is financial or reputational risk for PSG and the Insurer. 3. Providing Updates The responsible PSG staff member will provide the complainant with updates and feedback. PSG’s Marketing department handles responses on HelloPeter and Social Media complaints, and feedback must be provided to them for review and posting. 4. Ombudsman Complaints Insurers handle Ombudsman complaints. Provide all required information to them for review and response to the Ombudsman. PSG must resolve complaints to the client’s satisfaction within four weeks, failing which the matter can be referred to the Ombudsman. 5. Ombudsman for Short Term Insurance (OSTI) Contact Details Telephone: +27 (11) 726 8900 or 0860 726 890 Fax: +27 (11) 726 5501 Email: [email protected] Postal Address: P.O. Box 32334, Braamfontein, 2017 6. Record Keeping Keep a full record of all complaints received for five years. 7. Reporting Complaints Report complaints at various forums: PSG Manco - Monthly Insurer Bi-monthly Meetings Customer Experience Forum Committee - Quarterly Product Governance Committee - Monthly 8. Expectations Insurers are expected to handle complaints promptly, fairly, and transparently. Keep policyholders informed of the progress and resolution efforts. Regulatory bodies monitor insurers’ handling of complaints to ensure compliance with industry standards and regulations, emphasizing fair treatment of customers and efficient resolution of disputes.