Kathmandu: Insurers, who are facing challenges in investigating suspicious and complex claims, will now be able to outsource experts to investigate the claim.. For suspicious and complex insurance claims, insurers will be able to fully delegate the responsibility of investigation to licensed professionals or organizations that have expertise in investigation.
The Government of Nepal recently implemented the provision related to claim investigators for the first time through the Insurance Regulations 2081. Section 65 of the Regulation provides that any insurer may appoint a claims investigator to investigate whether the claim is in accordance with the insurance policy or not and whether there is any fraud or forgery in the insurance.
This provision, introduced for the first time in the insurance sector of Nepal, will make it easier for the insurer to transfer the responsibility of investigating complex and suspicious insurance claims to a third party and make decisions based on reliable investigation reports.
Through claim investigation, the insurer will not have to face any legal problems in the future regarding claim payment. The third party will remain fully responsible for this. The regulatory Nepal Insurance Authority will also hold the claim investigator responsible for the investigation.
In the case of the death claim of Sarjan BK from Kohalpur in Banke and Hazara Khatun from Kalaiya Bara, the life insurers faced legal troubles even while settling the claim based on the police report and the doctor’s report. In both these cases, the concerned police offices had proved that the the death was due to an accident.
What is a suspicious claim?
Insurers are hesitant to pay claims in cases where the insured dies immediately after the first installment is paid and the sum insured exceeds NPR 1o million. In recent times, some insurers have also tended to delay the death claim even for lower sum assured in the category of suspicious claims. In remote and hilly area with poor literacy and awareness on healthcare service, there is neither treatment documents nor a police report when the insured dies without receiving treatment. This situation is especially prevalent in the hilly districts of Karnali and the Far West.
For non-life insurers, especially in the event of fire damages, every claim seems to be doubtful. In Nepal, there has been a trend of setting fire to industries permanently rather than facing the hassle of managing the workers of an industry that is in loss, or having to destroy unusable raw materials or finished goods. The recent incident of insurance claim by the home appliances traders in Pokhara too is the burning example of fraud claim in property insurance. Even the recent Supreme Court ruling on the insurance claim for the fire at CG Electronics in Satungal by Chaudhary Group (CG Corp Global) also shows how complex fire claim investigation is in Nepal.
How much is the license fee?
The Insurance Regulations has not specified the tariff for the remuneration of the claim investigator. It can be agreed between the parties based on contractual agreement. To obtain a claims investigator’s license, a license fee of NPR. 5,000 and a Regulation fee of NPR 1,000 will be charged by the Nepal Insurance Authority.
