A provision that may be inserted in a policy to permit the collection of claims payments from some specified person overseas.
Tag: RAW
Claims processor
See: insurance billing specialist .
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US,MEDICAL: Employed representative of the insurance company who is responsible for handling insurance claims as they are received from patients and medical practices and who determines the dollar amount of a claim or debt. Also called adjuster, claims examiner, claims representative, claims administrator, or health insurance adjuster .
Claims representative
See: claims processor.
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Refer: “Adjuster.”
Claims Reserve
Claims provision, provision for outstanding claims/claims outstanding including Claims notified but not paid and claims that may have arisen but that have not yet been reported.
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Money designated to cover the claims that have occurred but have not yet been settled.
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UK: The provision made in the accounts of an insurer in respect of claims notified but not yet settled. See CHAIN LADDER METHOD.
Claims review
Audit by a peer review organization, insurance company, or other group of insurance claims submitted by a provider to validate payment or nonpayment, eligibility, or establish medical necessity of care and appropriateness of services provided.
Claims reviewer
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.
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.