of Insurance Company Lev Ins for organizing the activities related to insurance claim settling
1.1. The Internal Rules and Regulations herewith regulate the activities related the settlement of claims pursuant to insurance agreements.
1.2. The provisions hereunder shall not apply to the settlement of insurance claims for significant risks.
2. MANDATORY NOTIFICATION OF THE INSURER FOLLOWING THE ONSET OF INSURANCE EVENTS
2.1. The Insured shall notify the Insurer of the onset of an insurance event within the time period specified in the respective insurance policy. All notifications shall be in writing and the notification period shall commence the moment the Insured becomes aware of the occurrence of an insurance event. The notification periods for the different type of insurance products are as follows:
- Motor Hull Insurance: no later than 24 hrs for Theft and Robbery, no later than 72 hrs in case of Fire, and no later than 5 (five) working days for any other insurance evens;
- Motor Third Party Liability Insurance: no later than 7 (seven) days as of becoming aware of (i) the existence of circumstances establishing third party liability; (ii) of filing a claim; or (iii) of executing payments. The above shall not apply for the third party that has sustained the damage.
- Property Insurance: no later than 24 hrs as of the onset of insurance events for Clauses K1 – Burglary and/or K2 – Robbery and no later than 3 (three) days for any of the other insurance events;
- Cargo Insurance: within 3 (three) days;
- Accident Insurance: within 7 (seven) days;
- Overseas Medical Expense Insurance: no later than 7 (seven) days as of returning to Bulgaria (provided the Assistance Service has not been used); Should the Insured choose to use the Assistance Service, he shall notify the company providing the assistance by immediately reporting to the hotline shown in the policy;
- General Third Party Insurance: no later than 7 (seven) days as of becoming aware of the existence of circumstances establishing third party liability. No later than 7 (seven) days in case of filing a claim against the Insured by a third party that has sustained the damage.
- Various Financial Losses Insurance, Credit Insurance, and Guarantees Insurance: no later than 7 days as of the occurrence of the insurance event (the day on which, after becoming due and payable, payment of the repayment schedule has become outstanding – after the customary period of grace has expired and the debtor has failed to make due);
- Crops Insurance: within 5 (five) days;
- Livestock Insurance: within 3 (three) days;
2.2. The Insurer shall have the right to refuse payment if the Insured has failed to perform his obligations within the deadlines under Article 2.1 so as to impede the process of determining the circumstances of the insurance event and/or assessing the damages sustained; or when such non-performance has made it impossible for the Insurer to determine and assess such;
2.3. All notifications shall be in writing. The Insured shall send the Insurer a (to the Headquarters or through an agent) duly filled-in Insurance Event Notification Form (the form shall be enclosed with every insurance agreement). Notifications may be sent via fax or e-mail or delivered in-person to representatives of the Mobile Units. All notifications received will be recorded in a logbook by reference number and date.
The deadlines provided in Article 2.1. shall not apply to any third parties that have sustained damage.
3. FILING AND ACCEPTING CLAIMS PURSUANT TO INSURANCE AGREEMENTS
3.1. All claims will be filed in writing along with or following the respective notification. There shall be no deadline for putting forward a claim. However, the Insurer shall have the right to refuse payment if due to late submission it has proven impossible to determine the circumstances of the insurance event and the damages it has caused.
3.2. The Insurer shall enter every claim in a separate log dedicated to the respective insurance product. Each entry shall be dated and assigned a unique reference number issued in evidence of the fact that the respective claim has been duly entered;
3.3. The Insured shall be informed as to the unique reference number (Claim Reference Number) and the receipt date of his claim.
3.4. When entering a claim, the employees of the Insurer will furnish the customer with a list itemizing the evidence materials the latter is required to produce in order to prove the grounds of the claim and the extent of the sustained damage.
3.5. Should the employee receiving the claim decide, based on a preliminary review of the documentary evidence, that there are grounds to dismiss the claim and refuse payment (for example: the person filing the claim is not the owner of the insurance thus not having the necessary rights and authority; the insurance agreement was not in effect as of the date on which the insurance event occurred; no insurance event related to a covered risk has taken place; the event qualifies as an exception; or for any another reason), the said employee shall notify the claimant but shall not refuse him the right to enter the claim in the Special Claims Register. In any case, the Company shall issue a conclusive statement regarding the claim within the provided time period and in accordance with the applicable terms and conditions.
4. GATHERING EVIDENCE TO DETERMINE THE GROUNDS FOR THE CLAIM AND THE EXTENT OF THE DAMAGE CLAIMED
4.1. It is the responsibility of the Insured to prove the grounds of a claim and the extent of the damage. For this purposes the Insured shall:
4.1.1. Provide the Insurer with all of the documentary evidence required under the General Terms and Conditions applicable for the particular insurance product as set forth in Attachment 1 to the Rules and Regulations herewith.
4.1.2. Furnish the Insurer with any additional documentary evidence as the Insured may from time to time request in accordance with Article 105, Par. 3, Item 4 of the Insurance Code;
4.1.3. Preserve the insured property in the same condition as of when the insurance event occurred;
4.1.4. Give the Insurer the opportunity to inspect the property damaged as a result of the insurance event.
4.2. When the claim has been filed by an insured person, the Insurer shall instruct him as to the additional documentary evidence (not explicitly mentioned in the insurance agreement but directly connected to the event and deemed necessary so as to prove the grounds of the claim and the extent of the damage) that he may be required to submit no later than 45 days as of submitting the evidence expressly required under the insurance agreement.
4.3. If a claim has been filed by a damaged party under the Third Party Liability Insurance or by any other third party that is the beneficiary under a given policy, the Insurer shall instruct that person on the evidence he is required to submit in order to prove grounds for the claim and the extent of the damage. Additional evidence will be required only if the objective necessity of such could not have been reasonably foreseen at the time of filing the claim and shall be furnished no later than 45 days as of providing the evidence required under the previous sentence.
4.4. The claimant will not be required to provide evidence: (i) that he himself does not have access to by law; (ii) which he could not acquire since there is no legal provision allowing him to; (iii) that, as it might be reasonably concluded, has no material relevance for determining the grounds of the claim and the extent of the claimed damage, or such that are deemed to unreasonably complicate and procrastinate the settlement of the claim.
4.5. The employees of the Insurer shall undertake to explain to the customer his rights under Article 106 of the Insurance Code regarding the determination of an insurance event and the damages caused as a result of it (the right to receive information by the authorities within the Ministry of the Interior, by the authorities in charge of investigating the circumstances of the insurance events, by other government authorities, by the personal physician, by hospitals and healthcare institutions, and by any other parties authorized to certify the occurrence of insurance events, as well as the right to receive registered copies of records), and shall assist them in receiving such information and documents.
4.6. The employees of the Insurer shall certify acceptance of such evidence by signing an inventory list itemizing all pieces of documentary evidence submitted. The inventory list shall be filed along with the rest of the evidence and a copy of it shall be presented to the Insured.
5. INSPECTION AND ASSESSMENT OF THE SUSTAINED DAMAGE
5.1. The damaged property will be examined to certify the occurrence of an insurance event and to assess the damages. The inspection will be performed by a panel consisting of a representative of the Insurer (expert) and the Insured (or a duly authorized representative thereof). On the sole discretion of the Insurer an independent consultant may be the hired to participate in the inspection at the cost and expense of the former.
5.2. Should the Insured disagree with the findings of the inspection, he may arrange for a second inspection to be performed by an independent expert. The cost of such inspection will be borne by the Insured. Should the two different inspections yield different results and the parties fail to reach a mutually acceptable compromise, a third inspection will be carried out by an independent expert appointed with the approval of both parties. The cost of such inspection will be shared by the parties equally. The results of the third inspection will be final and conclusive. Should the parties fail to reach a mutually acceptable agreement, the dispute will be brought to the attention of a competent court by the discontent party.
5.3. The damages discovered during the inspection will be described in a Findings Protocol. The Findings protocol will be executed in three identical copies. The first copy will be enclosed with the Claim File, the second will be given to the Insured and the third, to the expert participating in the examination. The Findings Protocols will be signed by all members of the examination panel.
- Pictures will be taken during the examination to serve as evidence of the findings.
- The damages will be assessed based on the findings of the examination. If necessary, the services of expert appraisers will be used to assess the damages.
6. BUILDING UP THE COMPLAINT FILE AND DETERMINING THE INSURANCE AMOUNT TO BE PAID OUT
6.1. Every complaint file will contain the following:
6.1.1. Inventory list of all documents requested by the Insurer and provided by the Insured;
6.1.2. The documents furnished by the claimant;
6.1.3. The findings of the examination panel appointed to conduct the examination as well as any statements by other experts and appraisers;
6.1.4. Comparative analyses and calculations used to assess the damages;
6.1.5. Documents and statements issued by the competent authorities with regard to the case;
6.1.6. A report quoting the insurance amount to be paid out or concluding that such payment should be refused;
6.2. The amounts to be paid out under the Third Party Damage Insurance for car owners will be determined by the insurance carrier of the party causing the insurance event in accordance with the provisions of Ordinance 24 of March 8, 2006 on the mandatory insurance under Article 249, Par. 1 and Par. 2 of the Insurance code and the terms and conditions for settling claims for damages caused by vehicles (promulgated in State Gazette, issue 25 of March 24, 2006).
6.2.1. For the purposes of the mandatory Third Party Damage Insurance for car owners, insurance events will be certified by submission of the documents provided for in the Traffic Act, the Regulation on the Implementation of the Traffic Act and all of the by-laws regulating the implementation of the Traffic Act; or by any other official document issued by the authorities within the Ministry of the Interior or any court.
6.2.3. Where the extent of the liability under the Third Party Damage Insurance for car owners is determined by the court, once the sentence or the ruling of the court have taken effect, the eligible party shall furnish the Insurer with a certified copy of the said ruling or sentence, the reasoning for such and an original copy of adjudication order.
6.2.4. Upon death or injury of third parties the amount to be paid out by the Insurer shall be determined either by a panel of experts appointed by the Insurer carrying the insurance of the party causing the event or by the court of law. ZMEK will be subject to the provisions of Attachment 2 hereunder.
6.3. The insurance payments under the rest of the insurance products will be determined in accordance with the following principles:
6.3.1. If the insured property has sustained damage, the amount of the payment cannot exceed the value of the damaged property. The actual value of the damaged property will be assessed by a panel of experts appointed by the Insurer and cannot exceed the property’s market value as of the day on which the insurance event occurred.
6.3.2. If the property is insured for more than its actual value, the Insurer will be liable to pay damages up to the actual value. In such cases the Insured shall not be responsible to refund any excess premium paid in except where the Insured has acted in good faith.
6.3.3. If the property is insured for less than its actual value, the Insurer will calculate the damage to be paid out on a pro-rata basis.
6.3.4. If the insurance was placed under a First Risk Condition, the damage will be paid out in full but up to the maximum insurance amount;
6.3.5. If the insurance was placed under the condition that damages should be paid out based on the cost of replacement, the amount to be paid out will be calculated based on what it will cost to replace the damaged property including all reasonable costs for delivery, construction, installation, etc. No depreciation shall be applied in such cases.
6.3.6. The Insurer will be liable for all reasonable costs related to salvaging damaged property including transportation, loading and unloading expenses within the insurance amount.
6.4. When compiling the report under Article 6.1.6. above, the authorized employee of the Insurer will make sure that the grounds and the amount of the claim have been duly acknowledged and that the following criteria have been met:
6.4.1. The insurance agreement was in effect at the time of occurrence of the insurance event;
6.4.2. There are no outstanding premiums;
22.214.171.124. Where at the time of occurrence of the insurance event a portion of a premium has not yet been paid in full by the Insured, the Insurer, through an authorized employee of his, may withhold from the amount to be paid out the portion of the premium that was yet not paid in.
6.4.3. The insurance event is covered by the insurance agreement and there are no grounds for any of the exceptions to be applied;
6.4.4. The Insured has not defaulted on any of his obligations under the insurance agreement that otherwise would allow the Insurer to refuse payment;
6.4.5. All damages described in the Findings Protocol are eligible for coverage;
6.4.6. There is no underinsurance;
6.4.7. All documents part f the Claim File have been duly furnished;
6.5. The damages under the Casco Vehicle Insurance will be assessed in accordance with the principles set forth in the current section and the Special Rules outlined in Attachment 3.
7. REFUSAL OF CLAIMS
7.1. Claims will be refused under any of the following circumstances:
7.2. The insurance agreement was not in effect at the time of occurrence of the insurance event;
7.3. The insurance event is not covered in the agreement or is the result of an expressly excluded risk;
7.4. The Insured is in default on any of his responsibilities under the insurance agreement and such default, as per the agreement, constitutes grounds for refusal of payment;
7.5. The Insured has refused to provide documentary evidence necessary to prove the grounds for payment and such documentary evidence has been expressly requested by the Insurer in accordance with Article 105 of the Insurance Code;
7.6. The Insured has submitted fraudulent, forged, or counterfeited documentary evidence or has otherwise attempted to mislead or defraud the Insurer.
8. PAYMENT OF DAMAGES
8.1. All damages will be paid out within 15 days as of the date on which the Insured (or any third party sustaining any damage) has submitted all documents requested to ascertain the occurrence of the insurance event and to assess the damages but no later than 3 months as of filing the claim.
8.1.2. Should it be found that there are no grounds to honor the claim, or that the amount of the actual damage is less than what has been claimed, or that the grounds and amount of the damages have not been fully determined, the Insurer shall undertake to furnish the claimant with a motivated written statement within the deadlines set forth under Article 8.1.
8.1.3. If there are no grounds to dismiss a claim but some circumstances have not yet been clarified enough, the Insurer shall point them out and shall request the documentary evidence necessary to reach a determination in accordance with Article 105 of the Insurance Code;
8.2. Should the Insurer decide to honor a claim, the entire Claim File will be forwarded to Accounting for payment. All payments will be made in cash or by wire transfer as instructed by the Insured.
8.3. Once payment is made, the Accounting Department shall enter the date and the accounting document evidencing the transaction in the two original copies of the Report. One of these copies will be retained by the department and the other will be enclosed with Claim File.
9. REVIEW OF COMPLAINTS
9.1. The Insured may file complaints with the Company’s Records Department. All received complaints will be dated and assigned reference numbers. Complaints filed at our regional offices will be faxed to the Company’s headquarters immediately.
9.2. All complaints will be reviewed by the Executive Director. Complaints related to grounds for refusal will be handled by the Company’s Chief Legal Advisor.
9.3. All written replies to complaints will be reviewed and signed by the Company’s Executive Director.
10. PERFORMANCE DEADLINES
10.1. All claims will be registered upon receipt;
10.2. Damaged property will be examined immediately. Should it prove impossible to carry out the examination immediately, such shall be conducted no later than 3 days as of filing the claim.
10.3. The damages will be assessed within three days of conducting the inspection and receiving all documents constituting the complaint file.
10.4. The Damage Report will be executed no later than 5 days as of receiving all of the documents forming the Claim File.
10.5. The Report under Article 10.4. will be either approved or sent back for improvement no later than two business days after its submission;
10.6. A letter of refusal will be written, approved, and sent out no later than three days after the submission of a Refusal Report.
10.7. The Accounting Department will pay out the damages either by wire transfer or in cash no later than 2 days as of receiving the Claim File along with a payment report signed by authorized officers.
10.8. All complaints will be replied no later than 5 days as of receiving them at the Company’s headquarters be that by fax or by delivery in person at the Records Department.
11. FORWARDING CLAIM FILES FOR FILING COUNTERCLAIMS OR FOR SAFE KEEPING
11.1. All processed Claim Files found to contain grounds for counterclaims will be forwarded to the Counterclaims Department with the Damages Directorate at the Company’s headquarters.
11.2. All processed claims where no grounds for counterclaims have been found will be submitted for safekeeping after a payment is made or, alternatively, after a letter of refusal is sent (depending on the case).
11.3. All Claim Files processed at the agents’ offices where no grounds for counterclaims have been found will be forwarded to the Company’s headquarters once the concerned agent has undergone liquidation activity audit.
12. SUPERVISION OF CLAIM SETTLING
12.1. All activities related to settling claims will be supervised by Damages Directorate and the Audit Department by way of:
- Performing scheduled checks;
- Performing checks initiated by claimant complaints;
- Assessing compliance with the provisions of the Rules and Regulations herewith when performing liquidation activities (by reviewing all cases or by reviewing representative case samples);
12.2. Should any irregularities be detected during a review of a representative sample of cases, a review of all cases will be initiated.
13. FEEDBACK AND CUSTOMER SATISFACTION STUDIES FOR CLAIMS HANDLING
The Director of the Damages Directorate shall undertake to generate feedback from claimants who have been refused payment of damages. The feedback will be gathered by the agencies, the insurance agents, and broker by conducting interviews of the customers.
13.2. The Director shall compile summarized reports of the feedback and shall present them before the Board of Directors.