Last updated 31 May 2016

It is important that the proper procedure in making a claim is followed, as breakdowns in procedure may well translate to delays and less than full entitlement being received by the insured. Insurers are now allowed to give notices and information electronically and may often wish to do so.

Read the policy

After immediate matters are dealt with (e.g. putting out fires), the next thing an intending claimant should do is read the policy, including all of the following, as the case may be:

  • proposal
  • schedule
  • Product Disclosure Statement (PDS), including policy wording
  • relevant communications and file notes.

It is always better to deal with the insurer from a position of some knowledge.

Lodging a claim

The insured should take note of whether the insurance policy provides cover on an ‘occurrence-based’ or on a ‘claims-made’ basis, and must be careful to strictly and promptly comply with all obligations to notify the insurer should they become aware of a claim or circumstance which may give rise to a claim.

Claims service, including claims handling procedures, will vary from insurer to insurer. A good first step for a person making a claim is to telephone the company and find out if there will be one or a series of claims staff appointed to deal with the claim. If there is only one person, it is advisable to note their direct contact information.

Once the insurer has been contacted, there is a good chance the claims officer will have a standard procedure to follow in handling the matter. This may include:

  • taking the insured’s name and policy details
  • asking for a brief description of the loss and its cause
  • taking the basic claim details over the telephone or sending out a claim form
  • asking the insured person to obtain quotations to repair the damage
  • advising that a loss adjuster/assessor will be in contact to go through the claim on site.

Loss adjusters

Loss adjusters (or assessors) are either employees of the insurer or contractors to it. Their role is to assess liability and recommend what amount (or quantum) should be paid by the insurance company. Loss adjusters may either come from the ranks of the related trade (which is particularly common in motor vehicle claims), the insurance company, or from a legal or other background.

In motor vehicle claims, assessing centres are now quite common for damaged but driveable cars, and some insurers will ask its nominated repairer to also assess the claim.

Investigators

Investigators are usually appointed where a loss adjuster is not able to gather all the information desired by the insurance company. This could be for a number of reasons, including:

  • witness statements need to be taken
  • large claims need to be investigated according to company procedure
  • a certain type of claim (e.g. loss of all luggage) needs to be investigated
  • further investigation is necessary before accepting liability due to unusual or suspicious circumstances.

Investigators are sometimes retired police officers, and covert surveillance of an insured does take place from time to time. Unless the insured is concerned that something is wrong, assisting the investigator may be quite fair and reasonable. However, if there are any concerns, the insured should say nothing and obtain legal advice immediately.

Repairers

Various tradespeople and other professionals (e.g. engineers) may be involved in the claim process. As with adjusters and investigators, the insured should know what repairers are involved and what work they are doing. A copy of all relevant documents (including their reports) should be given to the insured person.

The work of repairers should be checked regularly and without delay. Quality issues with work should generally be directed first to the adjuster or directly to the insurer if no adjuster is appointed.

Service providers for the insured

Preparation of the claim may be an expense covered by the policy. The insured should review the policy and obtain insurer agreement in advance, but if in doubt take independent legal advice.

Public insurance adjusters, investigators, repairers and other professionals may be hired by the insured themselves to deal with insurance claim matters. It may be for the insurer to decide if they will pay for such representatives and indeed what weight, if any, is placed on their opinions. This will be a matter of negotiation and may be better placed in the hands of the insured’s solicitor.

Claiming on another’s insurance

Those claiming on the insurance of the at-fault party (e.g. a negligent truck driver) are often described by an insurer’s staff as third parties. They are a third party to the policy of insurance between the insurer and the insured. These third parties may wish to claim on another’s insurance, as they either have no insurance or do not wish to claim on their own policy for some reason.

Unless there is an unusual circumstance, such as a contractual arrangement between the third party and the insured, the insured has died or gone missing and cannot reasonably be found, there may be no legal entitlement for the third party to claim on a policy direct.

It is usually the case that cover is dependent on the insured:

  • making a claim themselves
  • passing on the third party’s claim and requesting cover for that also
  • meeting other contractual requirements, such as payment of an excess.

The third party should send a letter of demand with a time limit for compliance to the insured. Personal delivery of the letter is preferable. However, litigation is sometimes necessary before an insured will complete all required steps.