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  • Roger's claim

    Refer to Section 7 of the Code and Code of Practice website information on making an insurance claim to assist you in making the most appropriate choices for the following scenario.

    Select Start to begin.

    Start

    Roger is in urgent financial need of the benefits under his insurance policy, because of damage which has resulted in an insurance claim.

    Roger contacts you to make a claim and asks how long it will take for you to confirm whether or not you’ve accepted his claim as he is not in the best financial situation.

    How do you respond?

    Learn more about exceptional circumstances.

    “Well, that’s your problem. I’ve got ten cars in the lot waiting and my customers aren’t as patient as I am. What else can we do?”

    Roger sounds like he’s not as patient as you’d like him to be.

    What else could you do or say to resolve this potentially heated situation?

    10 days later Roger contacts you to follow up. You advise that there is a slight delay because you hadn’t collected all the required information.

    Roger angrily demands to speak with your supervisor.

    “Okay, that’s fine. What information do you need?”

    Although this is correct, it could take up to four months to make a decision from the date of the receipt of the claim. To avoid potential issues, what could be a more appropriate response?

    Although four months is a long wait, Roger is glad you’ve been direct and honest.

    As you’re about to close the call, Roger asks: “So what happens if I really need the money in order for my business to survive?”

    How do you respond?

    “Sounds fair enough. Well, let me know what info you need because I’m in a pretty tight spot right now”.

    You’ve said the right thing.

    What are some other options you could present that would be likely to result in the same favourable consequences?

    “That would be absolutely great.”

    Roger seems pleased with this potential solution. All you need to do now is gather evidence of his urgent financial need to achieve the appropriate resolution.

    Are there other solutions you could present that would be likely to satisfy Roger?

    “So you treat everyone the same. What nonsense! And what’s this Insurance Contracts Act all about? I don’t remember signing anything like that…”

    Roger seems frustrated. Perhaps there are other solutions you could have provided in line with the code of practice.

    Refer to section seven.

    "And if you don’t get back to me within those four months… What happens then?"

    How do you respond?

    “Well that sounds reasonable enough. Okay where to from here?”

    Roger seems satisfied with your response.

    Gold star!

    Are there any other choices you could make that would end in similar favourable outcomes?

    “ What about YOUR business, which is to settle my claim. The way you're going, I doubt you’ll be around much longer…”

    Oops! Okay, let’s retract that last choice and take another approach.

    “Well that sounds reasonable enough. Okay where to from here?”

    Roger seems satisfied with your response.

    Good work.

    Are there any other choices you could make that would end in similar positive outcomes?

    “OK, fair enough”.


  • Assessment and validation


  • Checkpoint

    Imagine your organisation decided to deny Roger’s claim.

    Which of the following actions would you need to take?


  • Start

    Now imagine that you were able to accept Roger’s claim. He contacts you a month after you have authorised a repairer to undertake the relevant restorative repairs.

    "Yeah, hi there. Look, you sent out a repairman and they’ve done a really bad job. The downlights they’ve put in aren’t even in a straight line! When I spoke to the guy he disagreed and insisted that the lights could light different parts of the workshop. Look, I just need to know what actions I need to take to get this issue attended to… Pretty bad customer service, if you ask me".

    How do you respond to Roger's dilemma?

    “Why do I need reports? I just want you to fix the zig-zag down lights is all”.

    Although it would be appropriate to supply service supplier reports if your organisation rejected Roger’s claim, in this case, you’ve actually undertaken the repair work.

    How else could you address Roger’s issue?

    “Well, this is a complaint so that makes sense. What do I need to do?”

    Nice. You’ve dealt with this issue like a true insurance professional. There is one other way you could respond…

    “And so you should. Thanks. Sorry for being a little aggravated. I just really didn’t expect the abstract light art in my ceiling”.

    Although slightly flustered, Roger is receptive to the solution you are proposing. Nicely done!

    Click.

    You realise when hear the dial tone that Roger has ended the call.

    This can’t be good…

  • Case study: appointing a loss assessor

    Steven Yau lodges his claim with an insurer on June 15. The insurer appoints a loss assessor on June 16. The assessor contacts the customer on June 17 to arrange an appointment. The insurer advises the customer of the assessor's appointment on June 18.

    Refer to sections 7.11–7.15 of the Code.


    Did the insurer comply with the Code's requirements for notifying the customer of the appointment of an assessor?

    What issue/s can you identify with this situation based on the provided facts?

    How you could avoid this situation happening in your workplace?


Exceptional Circumstances means:

  1. the claim arises from an extraordinary Catastrophe as declared by the ICA Board;
  2. the claim is fraudulent or we reasonably suspect fraud;
  3. there is a failure by you to respond to our reasonable inquiries or requests for documents or information concerning your claim;
  4. there are difficulties in communicating with you in relation to the claim due to circumstances beyond our control; or
  5. you request a delay in the claims process
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