Insurance company’s reimbursement employee who analyzes insurance claims similar to an auditor who checks procedure and diagnostic codes, prior authorizations, insurance contract violations, and so on.
Tag: RAW
Claims series clause
A clause in a liability or reinsurance contract designed to treat a series of loss occurrences unified by a common cause as a single loss. This means that any deductible or retention will be applied only to the aggregate of individual claims arising from the common cause and not to the claims individually. For example, individual claims originating in the same product design fault would be aggregated and might breach the deductible while each one individually might fall below it. The clause also has a bearing on the application of limits of indemnity. See HOURS CLAUSE; ORIGINATING CAUSE.
Claims Series Event, Product Liability Insurance
A claims series event is a series of two or more claims arising from one specific common cause which is attributable (i) to the same fault in design, manufacture instructions for use or labeling of products, or (ii) to the supply of the same products and/or services or to products and or service showing the same defect.
Claims Settling Agent
One instructed on behalf of an insurer both to assess a loss and to pay it on the insurer’s behalf.
Claims Sharing Agreement
An agreement between two property and liability insurers that in the event of claims arising in which both are interested on behalf of different parties, such claims shall be shared between them on some specified basis without regard to the degree of legal responsibility of the respective policyholders.
Claims transfer
See: crossover claim.
Claims Underwriting and Exchange (CUE)
Database containing details of nearly all household and private motor claims over a six-year period. The purpose is to combat fraud such as multiple claims for the same loss or the staging of a series of incidents. Underwriters may search CUE at the underwriting stage and avoid ‘bad risks’. More usually they search CUE when checking the validity of claims.
Claims-made basis
A form of reinsurance under which the date of the claim report is deemed to be the date of the loss event. Claims reported during the term of the reinsurance agreement are therefore covered, regardless of when they occurred. A claims-made agreement is said to “cut off the tail” on liability business by not covering claims reported after the term of the reinsurance agreement—unless extended by special agreement.
Claims-made coverage
A type of public liability insurance that responds only to claims for injury or damage that are brought (to the insurer) during the policy period (or during a designated extended reporting period beyond expiration). This development was in response to long tail claims, such as those related to asbestosis injury, carrying over many years and multiple layers of coverage limits. However, most public liability policies are written on an occurrence basis, covering injury or damage occurring during the policy period even if a claim is brought months or even years later.
Claims-Made Insurance
Liability Insurance which covers claims brought against the insured during the Policy period and are reported during the Policy period, regardless of when the injury or harm giving rise to these claims occurred.