ICOB 7
Claims
handling
ICOB 7.1
Application and purpose
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Application: who and what?
ICOB 7.1.1
See Notes
- (1) This chapter applies, except for ICOB 7.6, in respect of claims handling under a non-investment insurance contract to:
- (a) an insurer;
- (b) an insurance intermediary;
- (c) a managing agent.
- (2) ICOB 7.6 applies in respect of motor vehicle liability insurance business to:
- (a) a motor vehicle liability insurer; and
- (b) the Society.
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ICOB 7.1.2
See Notes
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ICOB 7.1.3
See Notes
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ICOB 7.1.4
See Notes
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ICOB 7.1.5
See Notes
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Purpose
ICOB 7.1.6
See Notes
- (1) The purpose of this chapter is to ensure that:
- (a) claims are handled fairly;
- (b) claims are settled promptly;
- (c) customers are provided with information on the claims handling process, and with an explanation of why a claim is rejected or not settled in full, where relevant; and
- (d) insurance intermediaries disclose and manage any conflicts of interest that may exist.
- (2) This chapter reinforces:
- (a) Principle 3 (Management and control), which requires a firm to take reasonable care to organise and control its affairs responsibly and effectively, with adequate risk management systems;
- (b) Principle 6 (Customers interests), which requires a firm to pay due regard to the interests of its customers and treat them fairly; and
- (c) Principle 8 (Conflicts of interest), which requires a firm to manage conflicts of interest fairly, both between itself and its customers and between a customer and another client.
- (3) The purpose of ICOB 7.6 is to transpose certain requirements of the Fourth Motor Insurance Directive
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ICOB 7.2
Group policies and third party claimants
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ICOB 7.2.1
See Notes
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ICOB 7.2.2
See Notes
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ICOB 7.3
Claims handling: general
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Requirement to handle claims promptly and fairly
ICOB 7.3.1
See Notes
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ICOB 7.3.2
See Notes
When handling the claim of a retail customer, an insurer should comply with the rules and guidance in ICOB 7.5. When handling the claim of a commercial customer, an insurer should ensure that:
- (1) the commercial customer is kept reasonably informed of how his claim is progressing; and
- (2) payment is made promptly once settlement terms have been agreed.
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ICOB 7.3.3
See Notes
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ICOB 7.3.4
See Notes
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Giving customers guidance on claiming
ICOB 7.3.5
See Notes
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Rejecting or refusing claims
ICOB 7.3.6
See Notes
An insurer must not:
- (1) unreasonably reject a claim made by a customer;
- (2) except where there is evidence of fraud, refuse to meet a claim made by a retail customer on the grounds:
- (a) of non-disclosure of a fact material to the risk that the retail customer who took out the policy could not reasonably be expected to have disclosed;
- (b) of misrepresentation of a fact material to the risk, unless the misrepresentation is negligent;
- (c) in the case of a general insurance contract, of breach of warranty or condition, unless the circumstances of the claim are connected with the breach; or
- (d) in the case of a non-investment insurance contract which is a pure protection contract, of breach of warranty, unless the circumstances of the claim are connected with the breach and unless:
- (i) under a life of another contract, the warranty relates to a statement of fact concerning the life to be assured and that statement would have constituted grounds for rejection of a claim by the insurer under ICOB 7.3.6 R(2)(a) or (b) if it had been made by the life to be assured under an own life contract; or
- (ii) the warranty is material to the risk and was drawn to the attention of the retail customer who took out the policy before the conclusion of the contract.
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ICOB 7.4
Duties of insurance intermediaries
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ICOB 7.4.1
See Notes
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ICOB 7.4.2
See Notes
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An insurance intermediary's duty of care, skill and diligence
ICOB 7.4.3
See Notes
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ICOB 7.4.4
See Notes
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An insurance intermediary's duty to avoid conflicts of interest
ICOB 7.4.5
See Notes
- (1) An insurance intermediary must not, in connection with any claim, put itself in a position where its own interest, or its duty to any person for whom it acts, conflicts with its duty to any customer, unless:
- (a) it made proper disclosure to its customer of all information needed to put its customer in a position where he can give informed consent to the arrangement; and
- (b) it has obtained the prior informed consent of the customer.
- (2) An insurance intermediary must decline to act for the person or customer referred to in (1) or any of them unless, in the particular circumstances of the case, disclosure and informed consent are sufficient to enable it to reconcile the conflict.
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ICOB 7.4.6
See Notes
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ICOB 7.4.7
See Notes
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ICOB 7.4.7A
See Notes
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Other notifications and actions in relation to claims
ICOB 7.4.8
See Notes
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ICOB 7.4.9
See Notes
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ICOB 7.4.10
See Notes
If an insurance intermediary is notified of a claim in relation to a policy which it has arranged, and the insurance undertaking has not given it the authority to deal with that claim, it must:
- (1) forward the notification to the insurance undertaking promptly; or
- (2) inform the customer immediately that it cannot deal with the notification.
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ICOB 7.5
Retail customers: performance standards for handling claims
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Responding to notification of the claim
ICOB 7.5.1
See Notes
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ICOB 7.5.2
See Notes
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ICOB 7.5.3
See Notes
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ICOB 7.5.4
See Notes
The response referred to in ICOB 7.5.1 R must:
- (1) provide the information set out in ICOB 7.5.5 R;
- (2) be in a durable medium, unless the notification by the retail customer is made orally and the insurer does not require the retail customer to complete a claim form; and
- (3) provide the retail customer with a claim form, if the insurer requires one to be completed.
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ICOB 7.5.5
See Notes
The information referred to in ICOB 7.5.4 R(1) is:
- (1) that the claim relates to a risk that is clearly outside the scope of the policy, if that is the case (in which case no further information need be provided);
- (2) the action that will be taken by the insurer, and when that action will be taken;
- (3) if the insurer is appointing any other parties to contact the retail customer on the insurer's behalf, in respect of each other party appointed the following information, if known (but, if the purpose of the appointment is to investigate the validity of a claim, the information need not be given if to give it would limit or prevent the effective investigation of the claim or any part of it):
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ICOB 7.5.6
See Notes
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ICOB 7.5.7
See Notes
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Investigation and processing of the claim
ICOB 7.5.8
See Notes
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ICOB 7.5.9
See Notes
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Determining the claim
ICOB 7.5.10
See Notes
An insurer must notify the retail customer as soon as practicable whether it:
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ICOB 7.5.11
See Notes
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ICOB 7.5.12
See Notes
If the insurer accepts all or part of the retail customer's claim, it must notify the retail customer as soon as practicable whether:
- (1) as to the parts it accepts, it agrees to provide the money, property or service claimed by the retail customer in full; or
- (2) it makes some other offer in compromise. In that event, it must notify the retail customer of the terms of its offer.
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ICOB 7.5.13
See Notes
- (1) Unless the insurer accepts the retail customer's claim in full, the insurer must explain why it rejects all or part of the retail customer's claim or makes a compromise offer, specifying any relevant term of the policy.
- (2) The insurer must offer the retail customer the choice of receiving the information at ICOB 7.5.13 R(1) in a durable medium.
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ICOB 7.5.14
See Notes
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ICOB 7.5.15
See Notes
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ICOB 7.5.16
See Notes
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Settling a claim
ICOB 7.5.17
See Notes
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ICOB 7.5.18
See Notes
- (1) Settlement terms are agreed when:
- (a) the insurer accepts the retail customer's claim; and
- (b) the retail customer accepts the insurer's offer of settlement.
- (2) When the insurer settles the claim by paying the retail customer, the insurer should aim to make payment within five business days after the insurer and the retail customer have agreed settlement terms, subject to any pre-conditions laid down by the insurer or in law being met by the retail customer. This does not prevent the insurer paying a claim before the retail customer has finally agreed settlement terms.
- (3) The guidance in (2) would not apply if the non-investment insurance contract otherwise provides, or the insurer settles the claim by:
- (a) payment against a liability due on a future date;
- (b) the provision of goods or services;
- (c) making payments on a date specified by the retail customer; or
- (d) payment of the claim through an employer or other party on a monthly or some other basis;
- and in the case of (a) or (b) the insurer should make prompt payment or arrange for prompt provision of the goods or services after the insurer and the retail customer have agreed settlement terms.
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ICOB 7.5.19
See Notes
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ICOB 7.5.20
See Notes
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ICOB 7.5.21
See Notes
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Pre-action protocols
ICOB 7.5.22
See Notes
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ICOB 7.6
Motor vehicle liability insurers: claims representatives
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ICOB 7.6.1
See Notes
- (1) Under threshold condition 2A (Appointment of claims representatives), if it appears to the FSA that any person is seeking to carry on, or is carrying on, motor vehicle liability insurance business, that person must have a claims representative in each EEA State other than the United Kingdom.
- (2) If any person carrying on motor vehicle liability insurance business becomes aware, or has information which reasonably suggests, that that person has failed to satisfy, may have failed to satisfy or may not in the foreseeable future be able to satisfy, threshold condition 2A (or any threshold condition), that person must notify the FSA immediately (see SUP 15.3.1)
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ICOB 7.6.2
See Notes
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ICOB 7.6.3
See Notes
- (1) When a motor vehicle liability insurer appoints a claims representative, it must give the MIIC, and each other information centre, the claims representative's name, business address, telephone number and effective date of appointment within ten business days of that appointment being made.
- (2) If the information at (1) changes in any material way, the motor vehicle liability insurer must be given the MIIC, and each other information centre, details of that change within ten business days of the change
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ICOB 7.6.4
See Notes
A motor vehicle liability insurer must ensure that each claims representative is:
- (1) resident or established in the EEA State for which it is appointed;
- (2) capable of examining cases in the official language or languages of the EEA State of residence of the injured party;
- (3) responsible for, and has sufficient delegated authority from the motor vehicle liability insurer for which it is appointed, to be able to:
- (a) handle and settle;
- (b) collect all information, and take all measures, reasonably necessary to negotiate a settlement of; and
- (c) represent, or arrange appropriate representation for, the motor vehicle liability insurer (whether in negotiations, in court or otherwise) in relation to;
- claims, arising from an accident occurring in an EEA State other than the EEA State of residence of the injured party, involving the use of a vehicle insured and normally based in an EEA State.
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ICOB 7.6.5
See Notes
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ICOB 7.6.6
See Notes
Nothing in the rules and guidance at ICOB 7.6 prevents, or is intended to prevent:
- (1) a motor vehicle liability insurer from appointing more than one claims representative in one, or more than one, EEA State; or
- (2) a claims representative from acting for more than one insurer or member; or
- (3) a representative, appointed by a motor vehicle liability insurer under SUP 13.5.2 or regulation 3(d) of the EEA Passport Rights Regulations, from acting as that motor vehicle liability insurer's claims representatives as well.
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ICOB 7.6.7
See Notes
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Motor vehicle liability insurers: claims handling
ICOB 7.6.8
See Notes
- (1) Within three months of receipt of a claim for damages from an injured party, or his representative, the motor vehicle liability insurer must (directly, or through a claims representative):
- (a) make a reasoned offer of settlement if liability is admitted and damages have been fully quantified; or
- (b) provide a reasoned reply to the points made in the injured party's claim if liability is denied, or not admitted, or the claim for damages has not been fully quantified.
- (2) If liability is initially denied, or not admitted, within three months of any subsequent admission of liability, the motor vehicle liability insurer must (directly, or through a claims representative) make a reasoned offer of settlement, if, by that time, the relevant claim for damages has been fully quantified.
- (3) If an injured party's claim for damages is not fully quantified when it is first made, within three months of the subsequent receipt of a fully quantified claim for damages, the motor vehicle liability insurer must (directly, or through a claims representative) make a reasoned offer of damages, if liability is admitted at that time.
- (4) A claim for damages will be fully quantified under (1)(a), (2) or (3) when the injured party provides written evidence which substantiates or supports the amounts claimed.
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ICOB 7.6.9
See Notes
- (1) If the motor vehicle liability insurer, or its claims representative, does not comply with ICOB 7.6.8 R(1)(a), (2) or (3), the motor vehicle liability insurer must pay simple interest on any damages eventually paid, unless interest is awarded by any tribunal which determines the injured party's claim.
- (2) If (1) applies, the amount of interest that the motor vehicle liability insurer must pay must be calculated as follows:
- (a) the interest calculation period begins three months after:
- (i) receipt of the claim for damages, if the motor vehicle liability insurer or its claims representative breaches ICOB 7.6.8 R(1)(a); or
- (ii) any subsequent admission of liability, if the motor vehicle liability insurer or its claims representative complies with ICOB 7.6.8 R(1)(a) but breaches ICOB 7.6.8 R(2); or
- (iii) the subsequent receipt of a fully quantified claim for damages, if the motor vehicle liability insurer or its claims representative complies with ICOB 7.6.8 R(1)(a) and (2) but breaches ICOB 7.6.8 R(3); and
- (b) the interest calculation period ends on the date when the motor vehicle liability insurer pays compensation to the injured party, or the injured party's authorised representative;
- (c) the interest rate to be applied throughout the period in (a) to (b) is the Bank of England's base rate (from time to time), plus four per cent.
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ICOB 7.6.10
See Notes
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ICOB 7.6.11
See Notes
- (1) ICOB 7.6.8 R to ICOB 7.6.10 R apply only to claims for damages for loss or injury suffered in, or as a result of, an accident which occurs in an EEA State other than an injured party's usual state of residence, which is caused by the use of a motor vehicle insured and normally based in an EEA State.
- (2) The rules and guidance at ICOB 7.6.1 G to ICOB 7.6.10 R are not intended to, and do not, restrict any rights which the injured party, or its motor vehicle liability insurer, or any other insurer acting on its behalf, may have and which would enable any of them to begin legal proceedings against the person causing the accident or that person's, or the motor vehicle's, insurers.
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ICOB 7.7
Record keeping
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