Thursday, 8 July 2021

Liability Insurance

 

                                                                    Liability Insurance

No Fault Liability

These claims can be made by depositing the appropriate amount with the MACT after obtaining death certificate, medical certificate and police report. In our lives, we often encounter situations where someone caused any harm. Whether it is property, material, spiritual, moral, labor, etc. And after that comes up is such a thing as a "liability insurance". Insurance can be of different types and refers to a variety of life situations. This type of insurance is used to shift the burden of responsibility on the shoulders of the insurance company and to protect themselves from unnecessary expenses. There are several types of liability insurance, the most basic.

 

(A) Public Liability Insurance: Industry and commerce are based on a range of processes and activities that have the potential to affect third parties (members of the public, visitors, trespassers, sub-contractors, etc. who may be physically injured or whose property may be damaged or both). It varies from country to country as to whether either or both employer's liability insurance and public liability insurance have been made compulsory by law. Regardless of compulsion, however, most organizations include public liability insurance in their insurance portfolio even though the conditions, exclusions, and warranties included within the standard policies can be a burden. Those with the greatest public liability risk exposure are occupiers of premises where large numbers of third parties frequent at leisure including shopping centers, pubs, clubs, theaters, sporting venues, markets, hotels and resorts.

 

(B) Product Liability Insurance: Product liability insurance is not a compulsory class of insurance in all countries, but legislation such as the UK Consumer Protection Act 1987 and the EC Directive on Product Liability (25/7/85) require those manufacturing or supplying goods to carry some form of product liability insurance, usually as part of a combined liability policy. The scale of potential liability is illustrated by cases such as those involving Mercedes-Benz for unstable vehicles and Perrier for benzene contamination, but the full list covers pharmaceuticals and medical devices, asbestos, tobacco, recreational equipment, mechanical and electrical products, chemicals and pesticides, agricultural products and equipment, food contamination, and all other major product classes

 

(C) Professional Liability Insurance: Under this category fall into the insurance cases where a person has suffered damage due to errors in the work on a professional basis - the work of ignorant doctors, lawyers, engineers, etc.

 

(D) Directors and Officers Liability Insurance (D&O) - The D&O policy provides cover for the personal liability of Directors and Officers arising due to wrongful acts in their managerial capacity. Defence costs are also covered and are payable in advance of final judgment. This policy provides protection for claims brought against directors, officers and employees for actual or alleged breach of duty, neglect, misstatements or errors in their managerial capacity.

 

The Motor Vehicle Act 1988

 

                                                            The Motor vehicle Act 1988:

 

This is the class of Insurance through which a majority of the people recognize general Insurance and that too because it is compulsory for all motorized vehicles to have an Insurance policy against third party liability before they can come on road. Though this class of Insurance is the major source of premium earnings for the Insurance companies it is also the class which is showing the biggest losses. It is necessary to have knowledge of Motor Vehicles Act passed in 1939 and amended in 1988.

Walker Compensation:  In the old days, many of walker who were knocked down by motor vehicles and who were killed or injured, did not get any compensation because the motorists did not have the resources to pay the compensation and were also not insured. In order to safeguard the interests of walker, the Motor Vehicles Act, 1939, introduced compulsory insurance.

Compulsory for third Party Liability: The insurance of motor vehicles against damage is not made compulsory, but the insurance of third party liability arising out of the use of motor vehicles in public places is made compulsory. No motor vehicle can ply in a public place without such insurance

For purpose of insurance, motor vehicles are classified into three broad categories:

(a) Private cars

(b) Motor cycles and motor scooters

(c) Commercial vehicles, further classified into

(I) Goods carrying vehicles

(II) Passenger carrying vehicles e.g.

- Motorized rickshaws

- Taxis

- Buses

(III) Miscellaneous Vehicles, e.g.

- Hearses (funeral van)

- Ambulances

- Cinema Film Recording & Publicity vans

- Mobile dispensaries etc.

TYPES OF CLAIMS VEHICLE

Theft

Accident

Collision

Fire

Own Damage

 Repair Death

 Bodily injury

 Property damage

Loss or Damage (or “Own Damage”). The risks covered are :

a) Fire, explosion, self-ignition or lightning.

b) Burglary, house breaking or theft.

c) Riot and strike.

d) Earthquake (fire and shock damage)

e) Flood, typhoon, hurricane, storm, tempest, inundation,

cyclone, hailstorm, frost.

f) Accidental external means.

g) Malicious act.

h) Terrorist activity.

i) Transit by road, rail, inland waterway, lift, elevator or air.

j) Landslide /rockslide.

 

Motor Vehicles Act, 1988

Compensation for Damages: The Law relating to Torts is based on the principle that every injury should have a remedy. The concept of compensation and providing damages step in at this very instance. The implications of the word – ‘compensation’ is quite wide. It seeks to provide for the actual or the anticipated losses and does so under various heads and is often awarded subjectively on a case-to-case basis. The Motor Vehicles Act, 1988 has been described to be a welfare legislation aimed at providing relief to the aggrieved parties.

 

Amendment of Act: The Motor Vehicle Act, 1939 consolidated all the laws relating to motor vehicles but it had to be constantly amended in order to keep it up to date. With the advancement in road transport technology and development of the road network coupled with the change in the pattern of passenger transport, it was important that the act was amended in order to incorporate all the modern techniques relating to motor vehicles.

 

The Motor Vehicles Act, 1988 is an Act of the Parliament of India which regulates all aspects of road transport vehicles. The Act came into force from 1 July 1989. It replaced the Motor Vehicles Act, 1938 which earlier replaced the first such enactment Motor Vehicles Act, 1914. The Act provides in detail the legislative provisions regarding licensing of drivers and conductors, registration of motor vehicles, control of motor vehicles through permits, special provisions relating to state transport undertakings, traffic regulations, insurance, liability, offences and penalties etc. Further, in order to exercise the legislative provisions of the Act, the Government of India made the Central Motor Vehicles Rules, 1989.

 

A review group was thus set up in order to form a comprehensive legislation and based on the suggestions given, the Motor Vehicles Act, 1988 came into being on July 1, 1988. Sections 140-144 (Chapter X) dealt with no fault liability, while Sections 145-164 (Chapter XI) deals with insurance in third party claims and Sections 165-176 (Chapter XII) goes on to deal with claim tribunals. The act is considered to be welfare legislation. It is primarily focused on giving relief to innocent persons on the road who are often victims to accidents and then find themselves not having a claim to the compensation that they should otherwise receive.

A driving license was made mandatory for any of the drivers through the provisions of the MVA, 1988. The act also required the registration of a vehicle under the act which had a validity period of 15 years after which it could be further renewed for another 5 years. These provisions form the tip of the iceberg which extends to cover multiple other sections which goes a long way in making the MVA, 1988 a welfare legislation.

Various Aspects of the Motor Vehicles Act

Insurance and Third-party Claims -

Compulsory Insurance was introduced in order to safeguard the interests of the third party who would be a probable victim of an accident or an injury by the use of a motor vehicle. This gives the victim or the third party for that matter to make claims either from the owner of the motor vehicle or from the insurance party or from both of them as need be and as given in the provisions.

As per Section 147(5) of the Motor Vehicles Act1988 (MVA Act), the insurer has the responsibility to indemnify the persons or the class of persons that the corresponding policy aims to cover. This insurance to the third party was considered to be mandatory under the statute and was not to be overridden on the basis of any clause present in that insurance policy. It was laid out in National Insurance Co. Ltd. v Faqir Chand that “third party” was to include everyone except for the contracting parties to the insurance policy.

It was also said that any Government Vehicles were to be exempted from insurance, under Section 146(2) and Section 146(3), which is then covered by a special fund organised for the same purpose.

Pillion rider driving out of scope: The policy as provided in the act was to include and cover only third-party claims and nothing more. A passenger traveling in a private car or a pillion rider driving a scooter was to be kept outside the scope of the insurance claims. It was also held that the insurance company would not be held liable for the accident to the pillion rider as long as the scooter owner had a policy that did not cover for the rider as well. Similarly, it was ruled that if the owner of the goods were to travel with the goods in a vehicle, the insurance company was not to be liable in case of an accident that were to occur in the process.

 

Issuance of Certificate

  As per the Act, policy of insurance shall have no effect unless and until a certificate of insurance in the form prescribed under the Rules of the Act is issued. The only evidence of the existence of a valid insurance as required by the Motor Vehicles Act acceptable to the police authorities and R.T.O. is a certificate of insurance issued by the insurers.

 

Liability under motor vehicle Act:

 

The liabilities which require compulsory insurance are as follows:

(a) Any liability incurred by the insured in respect of death or bodily injury of any person including owner of the goods or his authorised representative carried in the carriage.

(b) liability incurred in respect of damage to any property of a third party;

(c) liability incurred in respect of death or bodily injury of any passenger of a public service vehicle;

(d) liability arising under Workmen’s Compensation Act, 1923 in respect of death or bodily injury of:

(i) paid driver of the vehicle; (ii)conductor, or ticket examiner (Public service vehicles); (iii) workers, carried in a goods vehicle;

(e) liability in respect of death or bodily injury of passengers who are carried for hire or reward or by reason of or in pursuance of contract of employment.

 

CLAIMS (OWN DAMAGE)

On receipt of notice of loss, the policy records are checked to see that the policy is in force and that it covers the vehicle involved. The loss is entered in the Claims Register and a claim form is issued to the insured for completion and return. The insured is required to submit a detailed estimate of repairs from any repairer of his choice. Generally, these repairs are acceptable to the insurers but they at times ask the insured to obtain repair estimate from another repairer, if they have reason to believe that the competence, moral hazard or business integrity of the repairer first chosen is not satisfactory.

 

Assessment

Independent automobile surveyors with engineering background are assigned the task of assessing the cause and extent of loss. They are supplied with a copy of the policy, the claim form and the repairer’s estimate. They inspect the damaged vehicle, discuss the cost of repair or replacement with the repairer, negotiate as per the indemnity, and submit their survey report. In respect of minor damage claims, independent surveyors are not always appointed. The insurer’s own officials or their own automobile engineers inspect the vehicle and submit a report.

 

 

 

Settlement

The survey report is examined and settlement is effected in accordance with the recommendations contained therein. The usual practice is to authorise the repairs directly with the repairer to whom a letter is issued to that effect. In this letter the repairers are also instructed to collect direct from the insured the amount of the excess, depreciation, salvage, etc.The repairers are also instructed to keep aside the salvage of damaged parts, if there are any, for being collected by the salvage buyer nominated by the Insurers. Or else, if the repairers are willing to retain the salvage, its value, as indicated by the surveyor, is deducted from the claim bill. On receipt of their final bill of repairs after completion of repairs and a satisfaction note or voucher from the insured that the vehicle has been repaired to his satisfaction, the payment to the repairer is effected. Sometimes, the repairer is paid directly by the insured in which case the latter is reimbursed on submission of a receipted bill from the repairers. In either case, discharge voucher or receipt is obtained. The Claims Register and the policy and renewal records are marked that the claim is paid indicating the amount of claim and the amount of salvage, if any.

 

Claims Documents

Apart from claim form and Survey report the other documents

required for processing the claim are:

(1) Driving Licence

(2) Registration Certificate Book

(3) Fitness Certificate (Commercial Vehicles)

(4) Permit (Commercial Vehicles)

(5) Police Report (Taxis, commercial Vehicle need F.I.R./ spot survey if loss is heavy or T.P. loss occurs)

(6) Final Bill from repairers

(7) Satisfaction Note from the insured

(8) Receipted bill from the repairer, if paid by insured.

(9) Discharge voucher (full and final payment)

 

 

 

Total Loss Claims

Whenever a surveyor finds that a vehicle is either beyond repairs or the repairs are not an economic proposition, he negotiates with the insured to assess the loss on a Total Loss basis - for a reasonable sum representing the market value of the vehicle immediately prior to the loss.If the market value is more than the insured value, the settlement will be brought about for the insured value. The Insured will be paid in cash and the Insurers will take over the salvage of the damaged vehicle which will thereafter be disposed of for their own benefit calling tenders through advertisements in newspapers. However, before the actual payment is made to the Insured, the Insurer will collect from him the Registration and Taxation books, ignition keys and blank TO. and T.T.0. forms duly signed by the insured, so that the salvage is usually not encouraged, unless insured desires, so as to avoid the hassle of salvage disposal.

 

Theft Claims

Total losses can also arise due to the theft of the vehicle and its remaining untraced by the police authorities till the end. These losses will have to be supported by a copy of the First Information Report (FIR) lodged with the Police authorities immediately after the theft has been detected. The police authorities register the complaint allotting it a number of the entry made in the Station Diary. This number which is usually known as SDE No. or C.R. No. (Crime Register) has to be quoted by the Insured in the claim intimation to the Insurers.

 

The police keep the investigations going until the vehicle is traced and delivered to its owner. However, if they do not succeed in recovering the vehicle after a period of, say 1-2 months, they file away the case certifying that the case is classified as true but undetected. This police certificate referred as “Non-Traceable” certificate is essential before a total loss following theft is settled by the insurers. The documents to be submitted by the Insured will be the same as those described above. If the R.C. Book and Taxation Certificate are also stolen along with the vehicle. It will be necessary for the insured to obtain duplicate ones from the Registering Authority and thereafter deposit them with the Insurers. The only additional documents will be addressed by the Insured to the R.T.O. informing about the loss of the vehicle due to theft and filing a Non User Form so that he is not made liable to pay the taxes. Some insurers also obtain from the insured a special type of a Discharge on a stamped paper whereby the Insured undertakes to refund the claim amount if the vehicle is subsequently traced and delivered to him by the police. He also undertakes in the Discharge Form to pay any taxes which may be outstanding against the stolen vehicle. The ignition keys R.C.Books etc. are preserved by the Insurer in their custody so that these are made readily available if the vehicle is traced at a later date. It is always prudent to inform the concerned Registering Authority by a Registered A/D letter that a total loss claim is being processed for payment in respect of the stolen vehicle and to request them not to transfer the ownership of the vehicle to any one. This will prevent the thief from disposing of the stolen vehicle.

 

THIRD PARTY CLAIMS

Section 165 of the Motor Vehicles Act 1988, empowers the State Governments to set up Motor Accident Claims Tribunals (MACT) for adjudicating upon third party claims. When a tribunal has been set up for an area, no civil court has any jurisdiction to entertain any claim falling under the tribunal’s jurisdiction.

The aggrieved party has to move the tribunal within a period of six months from the date of accident. While making the award, the tribunal has to specify the amount payable by the insurer.

The procedure for third party claims is briefly described as follows:

On receipt of notice of claim from the insured, or the third party or from the MACT, the matter is entrusted to an advocate. Full information relating to the accident is obtained from the insured. The various documents are collected and these include

– Driving Licence

– Police report

– Details of driver’s prosecution, if any

– Death certificate, coroner’s (PM report) report, if any (fatal claims).

– Medical Certificate (bodily injury claims)

– Details of age, income and number of dependants etc.

A written statement is then filed on the facts of the case with the MACT by the advocate. Eventually, if the award is made by the MACT, the amount is paid to the third party against proper receipt.

 

 

Compromise Settlements

Where their is clear liability under the policy, claims are negotiated with the third party to accept a compromise settlement, which if accepted by the third party, is registered with the MACT and its consent obtained. The cheque is deposited with MACT for disbursement to the rightful beneficiaries.

Lok Adalats

Pending cases with the MPACT where the liability under the policy is not in doubt are placed before the Lok Adalat or Lok Nyayalaya, for a voluntary and amicable settlement between the parties. A copy of decision in the prescribed memo and the cheque is deposited with MACT. Lok Adalat sessions are organized regularly by the insurance companies in liaison with the Legal Aid Board of each State and MACT to effect amicable settlement of third party claims.

 


 

 

 

 

 

 

 

 

 

 

Wednesday, 14 June 2017

CLAIMS AND SETTLEMENT

CLAIMS AND SETTLEMENT
Role
Name
Affiliation
Principal Investigator
Dr.Gyanendra Kumar sahu
Asst.Professor Utkal University
Content Reviewer
Dr.Gyanendra Kumar sahu
Asst.Professor Utkal University

Description of Module
Items
Description of Module
Subject Name
Law
Paper Name
Law of Insurance
Module Name /Title
Claims and settlement
Module No.
VI


Objective: After reading this module, the learners will have a clear picture of :
The Insurance Policy is taken by the consumers to compensate them in the event of happening of an unforeseen event. It is a hedge against unavoidable circumstances.
Learning Outcomes: If the insured does not suffer any loss no claim is paid to him. The premium is charged on yearly basis and no accumulation takes place. However the scenario is different in case of life insurance. If the insured dies during the policy period he gets the sum assured along with the bonus accrued under the policy if any. If the insured survives the policy period he gets the maturity amount accrued under the policy. In this lesson we shall learn the various aspects in settlement of life insurance claim.

Introduction
The Insurance Policy is taken by the consumers to compensate them in the event of happening of an unforeseen event. It is a hedge against unavoidable circumstances. In general insurance the loss is payable only on happening of some specific event. If the insured does not suffer any loss no claim is paid to him. The premium is charged on yearly basis and no accumulation takes place. However the scenario is different in case of life insurance. If the insured dies during the policy period he gets the sum assured along with the bonus accrued under the policy if any. If the insured survives the policy period he gets the maturity amount accrued under the policy. In this lesson we shall learn the various aspects in settlement of life insurance claim.
CLAIM SETTLEMENT Payment of claim is the ultimate objective of life insurance and the policyholder has waited for it for a quite long time and in some cases for the entire life time literally for the payment. It is the final obligation of the insurer in terms of the insurance contract, as the policyholder has already carried out his obligation of paying the premium regularly as per the conditions mentioned in the schedule of the policy document. The policy document also mentions in the schedule the event or events on the happening of which the insurer shall be paying a predetermined amount of money (S.A.). There may be three types of claim in life insurance policies– 1. Survival Benefit Claim 2. Maturity Benfit Claim 3. Death Benefit Claim We shall discuss hereunder the details of each category of claims.
Survival Benefit : Survival benefit is not payable under all types of plans. It is payable in endowment or money back plans after a lapse of a fixed period say 4 or 5 years, provided firstly the policy is in force and secondly the policyholder is alive. As the insurer sends out premium notices to the policyholder for payment of due premium, so it sends out intimation also to the policyholder if and when a survival benefit falls due. The letter of intimation of survival benefit carries with it a discharge voucher mentioning the amount payable. The policyholder has merely to return the discharge voucher duly signed along with the policy document. The policy document is necessary for endorsement to the effect that the survival benefit which was due has been paid. The survival benefit can take different forms under different types of policies.
Maturity Claim It is a final payment under the policy as per the terms of the contract. Any insurer is under obligation to pay the amount on the due date. Therefore the intimation of maturity claim and discharge voucher are sent in advance with the instruction to return it immediately. If the life assured dies after the maturity date, but before receiving the claim, there arises a typical problem as to who is  entitled to receive the money. As the policyholder was surviving till the date of maturity, the nominee is not entitled to receive the claim. The policy under such conditions is treated as a death claim where the policy does not have a nomination. The insurer in such a case shall ask for a will or a succession certificate, before it can get a valid discharge for payment of this maturity claim. In case the policy has been taken under Married Women’s Property Act, the payment of maturity claim has to be made to the appointed trustees, as the policyholder has relinquished his right to all the benefits under the policy. It is for this relinquishment of right that the policy money enjoys a privileged status of being beyond the bounds of creditors etc. If the maturity claim is demanded within one year, before the maturity it is called a discounted maturity claim. This amount is much less than the maturity claim.
 Death Claim If the life assured dies during the term of the policy, the death claim arises. If the death has taken place within the first two years of the commencement of the policy, it is called an early death claim and if the death has taken after 2 years, it is called a non early death claim.
The documents required for payment of maturity claim : (i) Age proof, if age is not admitted. (ii) Original policy document for cancellation. (iii) In case assignment is executed on a separate paper, that document has to be surrendered. (iv) Discharge form duly executed. (v) Indemnity bond in case the policy document is lost or destroyed, duly executed by the policyholder and a surety of sound financial standing.
The documents required for payment of a death claim. (i) An intimation of death by the nominee or a near relative. (ii) Proof of age if not already admitted. (iii) Proof of death. (iv) Doctor’s certificate who attended the deceased during his last illness. (v) Identity certificate from a reputable person who saw the body of the deceased life assured. (vi) Certificate of cremation or burial from a reputable person who attended the funeral. (vii) An employer certificate if any, of the deceased. If the policy has been assigned validly or if there is a valid nomination in the policy document, no further proof of title to the policy money is necessary. In other cases, the satisfactory evidence of title to the estate of the deceased is required from competent court of law. e.g. (i) A probate of the will, if a will has been executed by the deceased life assured. (ii) A succession certificate if no will has been left. (iii) A certificate from the Administrator General, if the total amount of the estate left does not exceed Rs. 2,000/-. In case there is a rival claim court’s prohibitory order may be required to prevent the insurer from making the payment to the nominee as mentioned in the policy document.
In case the life assured has disappeared Under Indian Evidence Act, 1872, Section 108, a person who has disappeared is presumed to be dead only if he has not been heard of for 7 years by those who would naturally have heard of him, if he had been alive. The claimant has to produce the decree of the court to the effect that the assured should be presumed to be dead. The legal heirs are required to keep on paying the premium payment till such court order is received failing which the policy will be treated as a paid up policy.
In case the premature death claim In case of a premature death claim, i.e. a death within two years of the commencement of the policy, the insurer asks from claimant documents in order to eliminate the possibility of any suppression of a material fact at the time of submitting the proposal. (i) Hospital treatment details where the assured was hospitalised. (ii) Certified copies of postmortem report (iii) The police investigation report if death is due to an accident or unnatural cause.
PROCEDURE OF CLAIM SETTLEMENT  Maturity Benefit If the policyholder lives through the duration of the policy and becomes eligible to get the maturity value it is called the settlement of a maturity claim. As the policyholder is alive, the nomination is of no significance. Age is normally admitted at the stage of the proposal. If it has not been admitted for some reason, it is necessary to submit the age proof before the payment of the maturity value. Much before the date of maturity the insurer sends the claim discharge voucher which has to be returned duly signed and witnessed along with the policy document for payment of the maturity value.
 Death Claim In case of the death of the policyholder at anytime during the duration of the policy, the claim amount becomes payable to the nominee mentioned in the policy document. The nominee or the nearest relative shall send an intimation of death of the policyholder to the insurer stating therein the fact of death, the date of death, cause of death and the place of death along with the policy number. Insurer deals with the death claim differently on the basis of the duration or the policy. If the policyholder has died within two years of the commencement of the policy, i.e., acceptance of risk which may be different from the date of commencement if the policy has been dated back it is treated as “early or premature claim” and if the death has occured after 2 yrs of the commencement, it is treated as normal death claim. In a normal death claim, that is if the life assured has died after two years of the commencement of risk, the insurer, on being intimated about the death of the policyholder, calls for the age proof, if not earlier admitted, the original policy document and proof of death. The proof of death can be a certificate from the municipal authorities under which cremation has taken place, or other local body like death registry. The claimant generally is required to fill in a form giving certain routine information about his title to the policy money and the information relating to death, which is normally called a claimant’s statement.
 Premature claim It is a premature claim if the death has occurred within two years from the commencement of the policy or the date of last revival, or medical examination. The insurer takes certain precautions before making payment under such a premature claim. It wants to satisfy itself that it is a genuine case i.e., the correct policyholder has died and that the cause of death does not go back to a date prior to the commencement of the policy. The duration of last illness is of vital importance to eliminate any fraudulent intention. Last medical attendants’ certificate, hospital report, burial certificate, employees’ leave record, if he was an employee in a reputed firm etc, are the different records examined and normally a senior officer is deputed by the insurer to make on the spot investigation, through neighbours, colleagues or doctor of the locality.
As the revival of the policy is a de novo contract of insurance, the insurer would like to verify whether the statement contained in the declaration of good health given at the time of revival is correct. If such a statement is proved fraudulent relating to a material fact, the claim, may be rejected. Life insurance is a contract of utmost good faith and good faith has to be observed, not only at the time of the proposal, but also at the time of the revival of the policy whenever it is done. In case there is a rival claimant to the insurance money, the insurer can get a valid discharge by paying to the nominee. The rival claimant can approach a court of law which may order to stop the payment till the case is finally disposed of. However if there is no nomination under the policy, the insurer shall await a valid title through either a will or a probate as a letter of administration or a succession certificate. It may take quite sometime to get such certificate from the court and in the meantime the family may suffer. A good agent therefore shall ensure that there is a valid nomination or assignment. If there is an assignment, the policy money is paid to the assignee. If there is a reassignment of the policy, it is necessary that a fresh nomination is done, as assignment invalidates the existing nomination. However, if there is a nomination in favour of the insurer for taking any loan, the nomination is said to be unaffected subject to the claim of the insurer. If the premature death has been due to an accident, it is necessary to get a police inquiry report in lieu of the attending physician certificate. Suicide, if it has taken place within one year of the beginning of the risk, exempts the insurer from the liability of the payment of the claim. The propensity to commit suicide is a moral hazard and is not expected to continue beyond one year. If the policyholder disappears and he has not been heard of for 7 years by those who would naturally have heard of him, if he had been alive, he is presumed dead as per Sec 108 of the Indian–Evidence Act, 1872. However, it is necessary to keep the policy in force during this period by payment of the due premiums on the due dates.
Claim concession Normally, a death claim becomes payable so long as the policy is kept in force by payment of due premium. In other words if the payment of premium is stopped and the grace period expires and if the death occurs thereafter the policy is treated as lapsed or paid up depending upon whether the premium has been paid for less than 3 yrs or 3yrs & more. Under a lapsed policy no claim is payable. In case of a paid up policy, only the paid up value is payable. However, some companies provide certain concessions with regard to the claim payment, if the policy has run for 3 yrs or more: 1. If the premiums under a policy have been paid for a minimum period of three full years, and the life assured has died within 6 months from the date of the first unpaid premium insurer pays the full sum assured instead of the paid up value and only the unpaid premiums for the policy year are deducted from the claim amount. 2. This concession is extended to a period of twelve months and the full sum assured is paid if the life assured dies within one year from the due date of the first unpaid premium, provided the premiums have been paid for a minimum period of 5 years subject to deduction of the unpaid premiums for the policy year.
 Ex Gratia claim When a policy has not acquired paid up value and claim concession rules are not applicable, nothing is payable in case of death. However some insurers relax the rules in favour of the claimant. If the premiums have been paid for more than 2 years and (a) the death occurs within three months from the first unpaid premium, full sum assured with bonus, if any, is payable ; (b) if the death occurs after 3 months, but within 6 months, half the sum assured is paid ; (c) if the death occurs within one year from first unpaid premium, notional paid up value is paid. Under the first condition, the unpaid premium with interest for the policy year of death will be deducted from the claim and no deduction is made in the other two conditions.
CLAIM SETTLEMENT OPTIONS Most claims are paid in single lump sum. In case of a small sum assured, this lump sum payment may become necessary for immediate needs. (However, where the sum assured is large the amount if paid in instalments would be a valuable aid to the family maintenance). It is surprising that adequate attention is not paid to this aspect of the settlement options either by the claimant, or by the agent or the insurer. The settlement options as available are not competitive in interest rates and therefore most claimants probably would not opt for it. Lump sum payments are most likely to be spent much faster leaving the family without the benefit of security. The family in the absence of the breadwinner may not have the foresight and the ability to look to the safety of the capital, rate of return, liquidity and ease of management of money. Many insurance companies world over are facilitating the management of the claim by offering a lot of options to the claimant. Life insurance can be described as the creation of capital and annuities as a method of distribution of capital. Life insurance companies therefore, can convert this capital into annuity payments as per the needs of the claimant. An agent would do well to advise the widow in this regard and help her to purchase a suitable annuity policy with this claim amount so that the family can look after itself smoothly for quite sometime. Annuities of various types are available, as has been discussed in the chapter on “Life Insurance Products”. Lump sum payment, let it be remembered, does not offer protection against the creditors of the beneficiary, while the payment through annuity payment does. For beneficiaries, inexperienced in the art of money management receiving guaranteed payments in instalment may be more desirable.
IRDA REGULATION ON POLICYHOLDERS PROTECTION The Insurance Regulatory and Development Authority has issued the Protection of Policyholders’ Interests Regulations, 2002. This regulation states the matters to be stated in the life insurance policy for the protection of policyholders interests. It also lays down the procedure to be adopted towards the settlement of claim under a life insurance policy.

 Claims procedure in respect of a life insurance policy (i) A life insurance policy shall state the primary documents which are normally required to be submitted by a claimant in support of a claim. (ii) A life insurance company, upon receiving a claim, shall process the claim without delay. Any queries or requirement of additional documents, to the extent possible, shall be raised all at once and not in a piecemeal manner, within a period of 15 days of the receipt of the claim. (iii) A claim under a life policy shall be paid or be disputed giving all the relevant reasons, within 30 days from the date of receipt of all relevant papers and clarifications required. However, where the circumstances of a claim warrant an investigation in the opinion of the insurance company, it shall initiate and complete such investigation at the earliest. Where in the opinion of the insurance company the circumstances of a claim warrant an investigation, it shall initiate and complete such investigation at the earliest, in any case not later than 6 months from the time of lodging the claim. (iv) Subject to the provisions of Section 47 of the Act, where a claim is ready for payment but the payment cannot be made due to any reasons of a proper identification of the payee, the life insurer shall hold the amount for the benefit of the payee and such an amount shall earn interest at the rate applicable to a savings bank account with a scheduled bank (effective from 30 days following the submission of all papers and information). (v) Where there is a delay on the part of the insurer in processing a claim for a reason other than the one covered by sub-regulation (4), the life insurance company shall pay interest on the claim amount at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by it.