1. In industrial cases, a representative of the insurer who investigates, evaluates, and negotiates the patient’s insurance claim and acts for the company in the settlement of claims. 2. Individual employed by an insurance company who assists in settlement of claims by investigating claims, approving claims that are valid, and denying claims that are invalid or fraudulent. Some claims examiners are individuals who operate independently and are hired by insurance companies to adjust a specific loss. Also called adjuster, claims processor, claims representative, claims administrator, or health insurance adjuster.
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Claims Expenses
The expenses of investing and settling claims, e.g., adjusters’ fees as distinct from the claims themselves.
Claims expenses/claims handling expenses
Direct costs of investigation and settlement as distinct from the payments of the claims themselves. Includes loss adjusters’ fees, court fees, etc. The indirect expenses, claims handling expenses, relate to the salaries and overheads associated with running a claims department.
Claims experience
The insured’s claims history with regard to the cost and frequency of previous claims. It is material for an insured to disclose his claims experience when proposing insurance. The term also describes the relationship between premium and claims experienced by an insurer for a particular class of business over a period of time.
Claims Experience Discount/Loading for Fire Insurance
Risks having sum insured (on buildings and contents of all blocks in one compound of one complex in one location) above Rs. 50 crore shall attract claims experience discount/loadings based on the incurred claims experience of all the policies covering the insured’s interest for preceding 36 months excluding the expiring policy period. If there be break available 36 months experience is to be taken into account.
Claims Frequency
The number of claims in a period per unit of exposure, such as, the number of claims per vehicle year for a calendar year or financial year or per policy over a period.
Claims Frequency Distribution
A statistical frequency distribution for claim frequency.
Claims handling agreements
Agreements between insurers involved in the same incidents or losses to settle matters between them by way of a prescribed formula rather than resort to costly and regular litigation. The knock-for-knock agreement has been replaced by the memorandum of agreement.
Claims Handling Expense Provision
A provision or reserve to cover the estimated expenses of settling all claims, reported and unreported, outstanding at the accounting date; often known as Unallocated Loss Adjustment Expenses (ULAE). It excludes external expenses and those which can be directly attributed to the settlement of individual known expenses (such as legal expenses and claims assessors’ fees) as these are commonly identified in statistics as a form of claim payment and thus provided for within the provision or reserve for outstanding claims, known as Allocated Loss Adjustment Expenses (ALAE). It usually includes expenses that are not directly attributable to specific claims department staff and premises cost allocations.
Claims handling expenses
expenses incurred in negotiating and settling claims, including the direct expenses of the claims department (loss adjusters’ fees, court fees, etc.) and any part of general administration expenses associated with the claims function.