Phases of the claims process

These are internal procedures of the insurance company, however, an overview allows us to understand this part of the insurance company’s business.

Receipt of the declaration

The processing of the claim begins with the declaration made by the insured once the incident involved has occurred. Normally, this is the first notice that the insurer has and, therefore, it is essential that this statement provides complete information on the causes of the incident and its consequences.

Opening a file

After learning of the claim, the insurer “opens a file” to which all the information and data obtained in the processing are subsequently incorporated.

Initial assessment of the claim

At the same time as the file is being opened, the insurer’s processing officer makes an initial assessment of its cost.

Initial verifications

The insurer’s initial checks are intended to determine whether to continue with the claim or to terminate the process. The insured party can receive one of three decisions:

• The claim is not covered: refusal is notified.
• The situation is clearly covered by the insurance. The insured party is compensated and the file is closed.
• If the case is complex, the claim must be processed further.

Intervention by the loss adjuster

A loss adjuster is a professional expert in the field to whom the insurer entrusts the task of economically assessing the consequences of the loss and analyzing its possible causes. The insurer’s decision on whether or not to accept the claim depends to a large extent on the loss adjuster’s report.

Settlement of the claim

Once all the investigations have been carried out, the cost of the claim has been assessed and the indemnity has been estimated (if applicable), the insurer will make one of the following decisions:

• To pay the corresponding indemnity or compensation.
• To pay the indemnity and cancel the insurance contract when it matures. This is a legal possibility and can therefore be applied to all policies. In some cases the contract is terminated due to the insurer’s decision and in others because the insured object ceases to exist and, therefore, the risk no longer exists (for example, in the case of a car insurance policy where the vehicle suffers sufficient damage to be written off).
• To refuse to pay the indemnity. Decision of the insurer when it is certain that the claim can be rejected in accordance with the terms of the policy. The insurer must provide all evidence leading to this decision and communicate this to the insured party.