Article 37 The compliance control requirements of key risk points in the claims process shall be embedded in the claims information system and realized through the control of the information system.
The operation of the claim information system should conform to the claim practice, and strictly regulate and guide the actual operation.
Article 38 The company shall ensure that all claim cases are handled through the claim information system to realize the whole process operation control. It is strictly forbidden to handle claims outside the system.
Thirty-ninth claims information system database should be established in the head office. The head office shall not authorize provincial branches to modify procedures and data. All procedures and data shall be modified according to the approval and operation records.
It is strictly forbidden to establish a database of claims information system in provincial and sub-provincial branches.
Article 40 The function setting of the company's claims information system shall meet the requirements of the internal control system, and shall at least include the following contents:
(1) The claims information system should be integrated with the data of reporting system, underwriting system, reinsurance system and financial system to realize seamless connection. The case information approved by the company's administrative examination and approval system should be automatically connected to the claims system. Can not be automatically connected, the administrative examination and approval opinions should be scanned and uploaded to the claims system.
(2) The claims information system should control the whole process of claims, including at least receiving reports, dispatching workers, surveying, filing, loss assessment (loss assessment), personal casualty tracking (survey), quotation, loss assessment, physical examination, data collection, adjustment, loss assessment, case closing, compensation, recovery and disposal of damaged materials, customer return visit, complaint handling and special case handling. The claim information system should accurately reflect the working time limit of each claim link and post in real time.
(3) The claim information system should be able to realize the hierarchical authorization setting of nuclear loss report, nuclear price report, physical examination, nuclear compensation and other important links. , the system will automatically submit it to the superior for review according to the authorization rules; Without the approval of the final claimant, the claim system can't print the loss list. Without the approval of the final insurer, the claims system will not be approved, and the financial system will not pay.
(4) Claims information system should set claims standards and formulas according to laws, regulations and terms.
(five) in the claims information system, it is not allowed to set the contents of liability exemption and indemnity deduction other than insurance clauses without authorization.
(six) the data of the claims information system should be complete, true and cannot be tampered with.
(7) The claim information system should have the function of anti-fraud identification and reminding, and prompt the situation that the time of getting out of danger is close to the start or end time of insurance and the number of claims in the insurance year is abnormal.
(8) The claim information system can supplement and correct the collected customer information in every link to ensure that the customer information is true, accurate and detailed.
(nine) the claim information system should have the function of image storage and transmission, gradually realize the whole process of electronic documents, and implement paperless operation; Encourage enterprises to use the function of remote video transmission system.
(10) The claim information system can appropriately simplify the claim process that meets the requirements of fast processing.
(eleven) the claim information system should strengthen the monitoring of one person and more posts, and it is strictly forbidden to use other artificial numbers.
Article 41 The company shall formulate an emergency handling mechanism to ensure that claims services such as receiving reports in case of system failure can be carried out in a timely and orderly manner. Article 42 The company implements a unified national or regional management model for reported cases, and does not centrally manage reported cases of institutions at or below the provincial level. All auto insurance claims must be entered and numbered through the report link of the system before entering the next process.
Article 43 A company shall establish an effective report screening mechanism, and gradually reduce the number of invalid reports through standardized telephone inquiries and timely return visits after receiving reports.
Article 44 If the reporting time exceeds 48 hours, the company shall set warning signs in the claims information system and enter the specific reasons. The company shall establish a supervision and audit mechanism for cases reported for more than 15 days.
Article 45 When receiving a report, the claims information system shall automatically inquire and prompt the previous report records of the same insurance policy or the same vehicle, including the case records of the subject vehicle as a third-party vehicle. Warning signs should be set up for those who report many times within 30 days to prevent repeated reports and reduce moral hazard.
Article 46 The Company shall actively guide the insured or the driver who caused the accident to report the case directly to the insurance company. If the repair unit and other institutions or individuals report the case on behalf of the insured, the Company shall require them to provide the true contact information of the insured and verify it with the insured. At the same time, the company should verify the case by checking the valid identity documents of the insured or meeting with the insured in subsequent claims.
Article 47 The personnel of the company who accept the report should carefully inquire about and record the report information, and the report record should be as detailed as possible, which should at least include the following contents: policy information, vehicle information, insurance information, informant information, driver information, accident situation, loss situation, accident treatment and rescue, etc.
After completing the report record, the informant or surveyor shall promptly explain the claim settlement process and the required certification materials to the informant or the insured in detail.
In order to facilitate customers to understand the compensation procedure and claim essentials, the company should provide customers with multi-channel and multi-way explanations. Article 48 The company shall establish a perfect and scientific scheduling system, and use information technology to accurately schedule and improve efficiency.
Article 49 The Company shall know the working status of the claim personnel, claim vehicles and claim tasks in real time through the dispatching system. Article 50 The company shall ensure the authenticity of on-site investigation information by means of mobile terminal, remote control or double-person investigation. Major and suspicious claims should be investigated by two or more people.
The company should intensify the retest of difficult and major cases, and make statistics on the first on-site survey, on-site survey and off-site survey.
The company shall establish an investigation emergency mechanism to prevent and properly handle the improper allocation of investigation resources that may occur in sudden major cases or peak cases.
Article 51 The survey report of claims settlement cases shall truly and objectively reflect the survey situation, and complete explanations shall be filled in for the important items in the survey report. Important items shall at least include: information on the accident vehicle, driver, accident cause, course and nature, time, place, survey contents, casualties, accident vehicle location and loss degree, signature of survey personnel, etc.
Site photos should clearly reflect the overall situation and loss of the accident. The company should take technical measures to prevent or identify the modification of digital photos.
Survey information should be entered into the claims system in time, and if it exceeds the prescribed time limit, it should be submitted to the superior management for assessment and punishment.
Fifty-second survey personnel should record customer information in detail, understand the accident situation, and conduct investigation and evidence collection.
The surveyor shall submit a written notice of claim to the customer and make necessary explanations to remind the customer to file a claim in time. The "Claim Notice" shall at least include: guidelines for claim settlement procedures, materials to be provided for claim settlement, time limit for claim settlement commitment, claim settlement telephone number, information of claim settlement personnel, ways and means for customers to inquire claim settlement information independently and other matters needing attention.
Article 53 Company investigators should collect true and complete customer information in the investigation process, and constantly improve and supplement it in the follow-up process.
Article 54 The company shall strictly manage the investigation entrusted by external institutions. The company shall formulate the qualification standards of external cooperation agencies and sign cooperation agreements with the entrusted investigation agencies. If a branch entrusts an external agency to investigate, it shall be approved and authorized by the head office.
Fifty-fifth enterprises are encouraged to print anti-counterfeiting fragile stickers or anti-counterfeiting fragile seals (labels) on specific parts to prevent damaged accessories from being maliciously replaced and strengthen the management and disposal of residual values of accessories. Mainly used in the following aspects:
(1) If the first-site damage assessment meets the conditions of automatic price verification, accessories that need to restore the residual value shall be attached.
(two) the first site can not estimate the damage, affixed to the damaged appearance accessories, easy to replace and possible damage accessories; For vehicles that need to be disassembled under supervision, paste them at the key points of disassembly.
(3) Accessories that cannot be confirmed in the water damage accident, such as computer boards.
Article 56 The Company shall, in strict accordance with the Insurance Law, relevant laws and regulations and the insurance contract, verify whether the accident is an insurance liability within the time limit prescribed by law. If the situation is complicated, it shall be approved within 30 days, unless otherwise agreed in the contract. If it does not belong to the insurance liability, it shall issue a notice of refusal to pay compensation to the insured within 3 days from the date of approval and explain the reasons. After the claim documents are scanned and stored in the system, the relevant claim documents should be returned and the signing formalities should be handled. Article 57 The company shall strengthen the management of filing process to ensure that the estimated loss amount is as accurate as possible. In principle, the company should file a case as soon as it reports it. After receiving the report, it should be filed in the claim information system in time. The system should be set with the function of mandatory automatic filing that has not been filed for more than 3 days.
Article 58 The company shall timely, comprehensively and accurately enter the estimated loss amount. If the case is automatically filed, estimated and finalized through the claims system, the final amount shall be determined with reference to the average claims amount of similar cases in history or other reasonable statistical data. The company should make clear the allocation rules according to different situations such as risks and injuries. Article 59 The company's loss adjuster shall accurately record the loss parts and items, put forward suggestions for repair and replacement, and input them into the claim information system in time. And ask the customer to sign to confirm the missing parts and articles.
Article 60 The loss assessor shall promptly explain the loss to the customer, and patiently and meticulously explain the loss assessment items, repair methods, types of accessories, maintenance amount, etc. The loss confirmation letter after the nuclear loss has passed shall be signed by the customer for confirmation. For the losses borne by customers themselves, it is necessary to clearly inform customers and explain them clearly.
If it is necessary to adjust the items and amount of loss assessment, the loss assessment personnel shall obtain the customer's consent and sign for confirmation.
Article 61 The company shall strictly control the loss assessment entrusted by external institutions. Article 62 The company shall establish a professional price declaration team, set up a price declaration module in the claims information system, and gradually realize the automatic quotation of commonly used accessories.
Article 63 The company shall maintain and update the price information of spare parts, promote the localization of price information, and ensure that the price information matches the regional market.
The company shall adopt the accessories produced by regular accessories enterprises approved and certified by relevant state departments, which conform to the original technical specifications and performance standards of accessories, have legal trademarks and pass the quality inspection. Article 64 The company should attach great importance to the management of line loss, strengthen the construction of line loss team and improve the professional skills of line loss personnel.
Article 65 The loss assessor shall carefully check the accident site investigation submitted by the loss assessor to determine whether it is consistent with the accident reported by the customer, whether the accident is true or false, and whether it belongs to insurance liability.
Encourage the company's loss-fixing personnel to review the contents of the Notice of Claim to be provided to customers, so as to ensure the accurate description of the claim materials to be provided.
Article 66 The loss assessor shall conduct remote online or on-site audit on the subject loss items, repair methods and estimated loss amount submitted by the loss assessor, and put forward audit opinions according to the parts price information provided in the quotation link.
Article 67 The claims information system shall automatically adjust the amount of outstanding claims according to the nuclear losses. If the amount of outstanding claims fluctuates greatly, a reminder sign should be set in the system. Article 68 The Head Office shall set up a professional management team to review personal injury cases (hereinafter referred to as "personal injury"), and the claims department below the provincial level shall set up a full-time personal injury tracking (investigation) and medical audit team or post to participate in accident investigation, injury investigation, handling and tracking, assistance in reconciliation, participation in litigation, data collection, document review and expense verification of personal injury losses. The company should formulate the practice of personal injury tracking audit to achieve the goals of early intervention, process tracking, full rescue and strengthening management and control.
In principle, the company should set up a special telephone line and arrange personal injury professionals to provide the insured or the victim with full consultation service on personal injury treatment.
The company should intensify personal injury investigation, and formulate the requirements, specific contents and investigation time limit of personal injury investigation.
Personal injury auditors should take the initiative to participate in the joint settlement of damage compensation between the insured and the accident victims, so as to facilitate the two sides to reach a satisfactory joint settlement result.
In case of litigation dispute between the insured and the victim, the Company shall actively assist the insured in handling the litigation case.
Article 69 In the process of personal injury tracking, the company shall promptly learn from the medical unit, the insured or the victim about the diagnosis and treatment plan, medication standards, follow-up treatment expenses, use of disability devices and other issues, and timely correct the estimated loss amount of outstanding compensation.
Article 70 According to relevant laws and regulations and insurance contracts, the Company reviews and pays for personal injury expenses on the principle of people-oriented and timely treatment.
Article 71 When personal injury requires disability appraisal, the company shall give priority to recommending and guiding the injured person to a local disability appraisal institution with high credibility for appraisal, so as to ensure the fairness and objectivity of disability appraisal. The Company shall follow up the evaluation process and evaluation results, and in case of any doubt, it shall promptly give feedback to the evaluation institution or request re-evaluation.
The company shall record "low disability and high evaluation" and "suspected disability" and feed them back to the relevant competent authorities. Article 72 When receiving and recording the claim materials delivered by customers, the company shall check whether the claim materials are complete on the spot according to the Notice of Claim and issue a receipt in time. The receipt should indicate the company recipient, the receiving time and the company consultation telephone number.
Article 73 If the Company considers that the relevant certificates and materials are incomplete, it shall promptly notify the applicant, the insured or the beneficiary in writing to supplement the materials. Article 75 The company's claim limit standard shall not be lower than the claim limit stipulated by laws, regulations and industries.
If the company cannot determine the compensation amount within 60 days from the date of receiving the claim and relevant certificates and materials, it shall pay the amount that can be determined according to the existing certificates and materials in advance. After the compensation amount is finally determined, pay the corresponding difference.
Article 76 The company shall negotiate difficult cases, make a final conclusion after fully respecting the facts, accurately applying the law, comprehensively evaluating the interests of all parties, and effectively communicating with customers, and feed back the results in time. Article 77 After paying all the losses, the company will automatically or manually close the case. After the case is closed, the right to claim again should be collected to the headquarters through the claim information system.
Article 78 The company shall clearly stipulate the conditions for cancellation, zero settlement and refusal to pay compensation, and strictly manage cancellation, zero settlement and refusal to pay compensation.
The right to handle cancellation and recovery cases is collected by the head office through the claims information system. Article 79 The Company shall make compensation within 10 days after reaching a compensation agreement with customers. The company shall promptly notify customers to receive insurance claims, and regularly clean up outstanding claims. The agreed compensation shall not be paid in advance.
Encourage enterprises to establish a quick settlement mechanism.
Article 80 A company shall set the payee's name, account number and bank name in the claims information system, and abide by the relevant provisions on anti-money laundering when making claims.
After the payment is successful, the company will notify the customer by phone, text message or written form.
Encourage companies to actively guide customers to agree on payment methods, and clarify the information such as the object of payment, bank and account number when insuring.
Article 81 If the insured is an individual, the company shall actively guide the insured to receive the insurance money by bank transfer. If the amount of insurance compensation exceeds a certain amount, it shall be paid in a non-cash way to a bank account with the same names as the insured, the victims of road traffic accidents and other persons who meet the requirements of laws and regulations.
All regions and companies can set the maximum amount of cash payment according to the actual situation.
Article 82 With the insured as the unit, the Company will pay the insurance compensation of more than 65,438+0,000 yuan in non-cash in strict accordance with the relevant payment and settlement regulations, and pay it to the bank account with the names of the insured, the victims of road traffic accidents and other persons who meet the requirements of laws and regulations.
All regions and companies can further restrict the use of transfer payment methods without endorsement, such as remittance and online banking, according to the actual situation.
Encourage enterprises to pay compensation by cashless payment.
Article 83 A company shall strictly control the risk of collecting insurance money by agents.
(A) strict "direct compensation" repair shop management
The company must strictly manage and supervise the repair units that have signed the direct compensation agreement (hereinafter referred to as the direct compensation factory).
1. The authority to report and investigate on behalf of the company shall not be granted to the direct compensation factory.
2. When making claims on behalf of customers, the direct compensation factory shall provide maintenance invoices, maintenance lists, the original power of attorney issued by the insured, identity certificates and other materials.
3. The Company will transfer the insurance indemnity to the bank account of the name of the repair company that undertakes the repair of the accident vehicle through the bank by means of transfer payment without endorsement function, and inform the insured by telephone or in writing.
4. The company will not sign or renew the "direct compensation" agreement for the repair unit that cannot provide the true contact information and authorization of the insured.
(two) strictly control other units or individuals to receive insurance claims.
For units or individuals other than the direct compensation factory to receive insurance compensation on behalf of the insured or road traffic accident victims, the original valid identity certificate, the original power of attorney and the original identity certificate of the claimant of the insured or road traffic accident victims shall be provided.
The method of paying compensation shall be implemented in accordance with the provisions of Article 8 1 and Article 82.
Article 84 After the insured causes damage to a third party and the insured's liability for compensation to the third party is determined, the Company shall directly compensate the insurance money to the third party at the request of the insured. If the insured's claim is slow, the third party has the right to directly claim compensation from the company for the part that should be compensated, and the company shall accept it. Article 85 The company shall strengthen the management of subrogation cases, formulate rules and regulations, and the business and financial handling methods and processes of recovery cases.
Article 86 The company shall formulate measures for the management of damaged materials. When the damaged materials are returned to the insured, they shall be agreed with the insured through consultation to ensure fairness and reasonableness.
When the company recovers the damaged materials, it should accurately enter the management information and disposal situation of the damaged materials in the claims information system, and count the disposal amount of the damaged materials. The payment should be deducted in time.
For the recovery of stolen vehicles and the disposal of damaged vehicles with presumed total loss, they should be handled by institutions at or above the provincial level.