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Claims

filing insurance claims

INSURANCE CLAIM CONDITIONS & MANAGEMENT

If you wish to report a new claim or discuss an existing claim, you can call us on 255 769 951 736. For motor claims use our convenient online claims process.

NOTE: These claim conditions will apply to all insurance products.

A claim: is a request/demand to be reimbursed or compensated filed by the insured or reinsured or a third party claimant and addressed to the insurer or reinsurer.

A claimant: is a person who lodges a claim, usually denotes that person hasn’t filed a lawsuit. Upon filling a lawsuit, they would be a plaintiff.

Claim expenses: Are the expenses associated with adjusting the claim such as court costs, fees, lawyers, independent adjusters, witnesses

Claim adjuster/loss adjuster: the one who investigates the loss and determines the extent of coverage. He is working on behalf of the insurer from the start to finish.

Loss assessors: are the experts who are dealing with insurance claims. They are appointed by an insured to prepare and negotiate the claim on their behalf. The fees are paid by the insured and the cost do not form part of the insured’s claim.

Log time: refers to time the date of injury to the time that claims are reported to the claim intake center.


LEGAL REQUIREMENTS FOR A VALID CLAIM

  1. Occurrence of a trigger event for the policy of insurance to pay (Perils that will trigger claim payment)
  2. Notification to the insurer of the claim
  3. Proof of loss and cover must be provided
  4. Legality of the claim
  5. Enforceability of the insurance contract – This must meet the enforceable contract requirements i.e Written and signed, offer and acceptance, consideration etc.
  6. The insurance contract must be appropriate to nature and cause of loss (Should not fall under exceptions)
  7. Deciding size of the loss – This is based on the actual damage or loss and the extent of insurable interest.

The information that must be immediately recorded:

  1. Date and time of loss
  2. Location of loss
  3. Nature or description of loss
  4. Person collecting information
  5. Person proving information
  6. Contact name and number or fax or email address
  7. Approximated quantum of loss
  8. Description on how loss occurred
  9. Confirmation of police involvement
  10. The contact details of other parties involved and the nature and extent of their loss (if any)
  11. Details concerning the insurance policy of the third party (if any)

NOTE: If in any way an Insurer doubts or proves that the claim is fraudulent then there will be consequences on the insured.

A fraud can be defined as an intentional deception made for personal gain or to damage another individual.

Consequences on the insured’s:

Genuine insured’s will also suffer as a result of increased premiums due to payment of fraudulent claims.

Cancelation of the policy

Avoidance of the policy ab initio (from the start)

Retention of premiums

Various criminal remedies

In the event of an accident you should provide the following information / documentation:

  • Details of the insured vehicle:
    • Copy of the vehicle registration card
    • Copy of the Insurance cover note
    • Copy of the Driver’s licence (front and back)
  • Police reports:
    • Preliminary police report – PF90
    • Vehicle inspection report – PF93
    • Sketch map
    • Final Police report - PF115
  • Estimate cost of repair from the garage.
  • Completed claim form
    • Do not admit responsibility or sign any statement to that effect. Contact us to report the incident as soon as possible

In case of third party involvement, the following will be required from the third party:

  • Details of the third party vehicle:
    • Copy of the vehicle registration card
    • Copy of the Insurance cover note
    • Copy of the Driver’s licence (front and back)
      Police reports:
    • Preliminary police report – PF90
    • Vehicle inspection report – PF93
    • Sketch map
    • Charge sheet
    • Court judgement
    • Final Police report – PF115
  • Estimate cost of repair from the garage.

If Your Car Is Stolen You Should:

  • Report the incident to the nearest Police Station and notify Mawenzi Insurance Brokers by calling 0769 951 736 as soon as you discover the vehicle is missing.
  • Get investigation report from the Police.
  • Complete the claim form and send us the completed claim form.
  • If your vehicle is not recovered within 14 days please send us the keys and original Vehicle Registration Certificate. If your car is recovered you should contact us 0769-951-736 immediately and let us know the location of your car.

A claim: refers to a request to be reimbursed filed by the insured and address to the insurer.

Loss: is the occurrence of an insured event, such as a fire

Policy holder: is a person who buys insurance but when they make a claim they are referred to as a claimant.

Excess: Is amount of deduction payable by insured from the net loss assessed. Per standard Excess rates, if the vehicle is stolen, Insured will be compensated by 90% and pay Excess (deductible) of 10%. If it’s a partial loss or total loss from accident, insured will pay 5% Minimum 350,000 for private vehicles or 500,000 for commercial rate – please refer to the rate chart for more specific excess applicable to your vehicle.

General Obligations Of Insurer

As a Mawenzi Insurance Brokers client here is what you can expect from us.

Insurer must:

  • Respond promptly
  • Give reasonable guidance
  • Handle claims fairly and promptly
  • Tell claimant how claims is progressing
  • Explain why not an insured peril or remote cause or why will you not pay
  • Settle claims promptly
  • Handle complaints fairly and promptly

The Insurer’s Responsibility:

  • Book the claim reported
  • Verify the insurance cover, policy conditions, and exclusions.
  • Assign Vehicle Assessor for the investigation of the accident and the cost of repair.
  • Assessor will submit the report to the insurer for approval to repair the vehicle
  • Provide the approval to the garage to fix the vehicle per the agreed terms and assessor’s recommendations
  • When the repair is complete, insurer sends the check to the garage or the insured based on the agreements.
  • If it’s a total loss, the insurer will give an offer for settlement less applicable excess

The insured’s Broker:

  • Receive the claim information from the insured and immediately report to the insurer accordingly.
  • Compile the claim information from the insured and submit to the insurer a completed claim package – per the insured’s check list above
  • Follow up with the insurer to complete their responsibilities and get the approval to repair the vehicle as quickly as possible
  • Negotiate fair settlement terms as necessary for the insured

Check List

For both Third Party, Third Party Fire and Theft an Comprehensive insurance

  • Claim Form – Dully completed and signed by insured and the driver
  • Vehicle Registration Card – copy
  • Current Cover Note (proof of insurance)
  • Driving License – copy of the driver involved in the accident
  • Driver’s Statement about the accident
  • Police Report (PF 90) – original
  • Police Sketch Maps of the accident
  • Vehicle Inspection Report (PF 93)
  • Police Final Report (PF 115) – if applicable, it’s a must for T/P cover
  • Estimated Cost of Repair – from car dealer or assigned garage

Claims that are designed to be filled once an individual pays for his or her medical bills while the policy has already put on force.

What is needed for one to be reimbursed:

  • Both signatures for the patient and the attending doctors on the claim form.
  • Fill in the claim form correctly
  • All the original receipts
  • Invoices where applicable
  • Laboratory/X-rays requests