INTRODUCTION Claims management is one of the most challenging business process in the insurance industry. A very important aspect of Insurance. Driving force in planting confidence in the hearts of people/ customers. It affords us other opportunities – use of data to analyze causes, trends profitability etc. Insurance at its basic a protection against a financial loss arising out of an unexpected event. An insurance claim is the actual application for benefits provided by an insurance company. It is a right of the insured. Technology can play an integral part by providing integrated channels for communication- it reduces cycle times People in the claims department should have good inter personal skills. CM means and includes all the managerial decisions and processes concerning the settlement and payment of claims, in accordance with the terms of insurance contract.

Functions of claims department To provide high quality service to customers of insurance and insurance companies. To monitor the claims and see whether the benefits of insurance exceed the cost of claims. To see that the expectations of customers are met with regard to speed, manner and efficiency of service To meet the standard of service, to keep up to the customers expectations (exceed) and still operate within budget. The overriding condition on claims is the payment of premiums i.e. claims are only payable if premiums are paid to date

Types Of Claims Death claims  Basic conditions that must be fulfilled depending on the type of claim. 1.Policy document, original death certificate?? Burial permit, copy of ID of deceased. 2.PMA report/Doctor who last saw the deceased. 3.Completed claim form. 4.Police abstract if death due to accident.  Maturity, paid up, surrender claims Will largely depend on type of policy but; 1.Policy document 2.Discharge from a must  Disability claims Sufficient medical evidence being provided.

Claims handling procedure Intimation of death to the office letter etc Submission of proof of death. Age proof Ownership of cover if individual cover. Payment and discharge Special requirements for early claims.

Factors affecting claims settlement 1.Cover should be in force * Credit life 2.Risk and cause of event should be covered by the policy. 3.Loss should not have been caused with an intention to gain from the situation. 4.Presumption of insurable interest. 5.Assured should suffer a loss. 6.Sufficient documentary evidence should be presented. 7.Help the agent/ broker to come to agreement with assured in case of a disputed claim. 8.Pay ex-gratia if the claim is totally baseless and non acceptable on humanitarian grounds or to protect commercial interests.

Investigating claims 1.Investigate when cause or documents are suspect. 2.Identify the right investigator 3.Assess costs of claim investigations VS claim amount

Frauds in insurance 1.Intent to deceive 2.Desire to induce insurance company to pay more than it otherwise would.  Two categories 1.Cause or claim is fraudulent 2.Claim may be genuine but how calculated the claim assumed payable of the evidence may be fraudulent * Avoid paying claims in cash.

Recent trends 1.Mobile technology in setting claims – MPESA, TISS. 2.Frauds on the rise check purpose of cover and duration of policy. 3.Claim documents appear easy to obtain. 4.Lack of integrity through all levels. 5.Don’t look for the Hay, look for the horse!

Finally Have adequate reinsurance protection. Consult RI-they have a wide experience.