Do you know the difference between a complaint and an insurance claim? What rule regulates these procedures?
What is a claim?
A claim consists of requesting or requiring in writing the insurer to restore a specific right or interest derived from alleged breaches on their part. It would be the case of claiming the payment of compensation to the civil liability insurance of the guilty car, which has not paid the relatives of the victim of a traffic accident after 4 months of being killed in a pedestrian crossing.
When claiming, in theory, the insurer looks at the matter and justifies its position, resolving the issue in favor of the user or against him.
What is a complaint?
A complaint is nothing more than denouncing neglect, delays, non-compliance or any other type of deficient performance of the insurer towards the user, whether insured or injured. The complaints are not intended to restore any rights, but they are the “preliminary” phase to file a complaint with the DGSFP ( General Directorate of Insurance and Pension Funds ) and that, in this way, the insurer is “sanctioned”.
The difference between complaint or claim
The ultimate purpose of the claim is to restore the legitimate rights or interests of the user, while the purpose of the complaint is to denounce the fact or anomaly in order to bring it to the attention of the insurer and, in another higher instance, request a sanction from the DGSFP so that the conduct do not repeat.
But it should be noted that if the insurance claim is not handled correctly and the DGSFP decides in favor of the user in a second phase, the same DGSFP can, “ex officio”, urge an administrative sanction on the insurer as if it had been a complaint-complaint.
What does the standard say? The obligation to go through the SAC of the insurer.
There are two regulations: Order ECO / 734/2004 , which regulates the functions, requirements and other aspects of the Customer Service of insurers to deal with user complaints and claims; and Order ECC / 2502/2012 , which regulates the procedure for submitting claims and complaints to the DGSFP if it turns out that the insurer has ignored the user, or the insurer has answered “nonsense”.
Basically the standard says the following:
- The user, whether insured or injured , may submit claims or complaints to the insurer , who must necessarily have a department enabled for this purpose (the SAC) which must have an enabled email address, a postal address and a person responsible for that department that must meet the requirements of an honest person, with knowledge, experience, …
- The maximum term that the insurer has to answer and resolve the claim is 2 months .
- The decision of the insurer will always be motivated and will contain clear conclusions about the request raised in each complaint or claim, based on the contractual clauses , the applicable standards of transparency and protection of the clientele, as well as good financial practices and uses. This means that the insurer must prove its resolution with evidence and objective evidence.