Part

ICOB Insurance: Conduct of Business

Chapter

Claims handling

Printed on: 15/11/2024

Rulebook at: 06/03/2006

ICOB 7

Claims
handling

ICOB 7.1

Application and purpose

  • 14/01/2005

Application: who and what?

ICOB 7.1.1

handbook-rule
  1. (1) This chapter applies, except for ICOB 7.6, in respect of claims handling under a non-investment insurance contract to:
    1. (a) an insurer;
    2. (b) an insurance intermediary;
    3. (c) a managing agent.
  2. (2) ICOB 7.6 applies in respect of motor vehicle liability insurance business to:
    1. (a) a motor vehicle liability insurer; and
    2. (b) the Society.
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ICOB 7.1.2

handbook-rule
Throughout this chapter, references to an insurer apply equally to a managing agent.
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ICOB 7.1.3

handbook-guidance
An insurer is responsible for claims handling. A managing agent is responsible for claims handling for policies underwritten at Lloyd's. An insurer or managing agent remains responsible for claims handling if it outsources any of its claims related activities, including where it gives an intermediary authority to handle claims on its behalf. An insurer or a managing agent is not responsible for the administration and performance activities that an insurance intermediary carries out on behalf of a customer in connection with a claim. In relation to these activities, the insurance intermediary should refer to ICOB 7.4.
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ICOB 7.1.4

handbook-guidance
An insurer should refer to the rules and guidance set out in SUP 2.3.5 to SUP 2.3.10 in respect of any person to whom it outsources its claims handling functions.
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ICOB 7.1.5

handbook-guidance
All of this chapter, except ICOB 7.6, applies to claims made by retail customers. Part of ICOB 7.3, all of ICOB 7.4 and all of ICOB 7.7 apply to claims made by commercial customers. ICOB 7.6 applies to claims by injured parties 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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Purpose

ICOB 7.1.6

handbook-guidance
  1. (1) The purpose of this chapter is to ensure that:
    1. (a) claims are handled fairly;
    2. (b) claims are settled promptly;
    3. (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
    4. (d) insurance intermediaries disclose and manage any conflicts of interest that may exist.
  2. (2) This chapter reinforces:
    1. (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;
    2. (b) Principle 6 (Customers interests), which requires a firm to pay due regard to the interests of its customers and treat them fairly; and
    3. (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. (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

handbook-guidance
Any person who, under the terms of a policy, has a right to claim directly on the insurer, is a policyholder (see ICOB 1.2.15 R to ICOB 1.2.16 G). When dealing with claims under group policies, insurers should consider whether the person claiming is a commercial customer or a retail customer and should apply the rules in this chapter accordingly when dealing with a customer's claim.
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ICOB 7.2.2

handbook-guidance
When an insurer deals directly with a third party who claims against his customer because the third party has a legal right to bypass the customer and claim directly against the insurer (for example, certain motor claims or because of the insolvency of the customer), these rules do not require the insurer to treat the third party as a customer. However, the insurer should have regard to Principle 1 (Integrity), Principle 2 (Skill, care and diligence) and Principle 5 (Market conduct) in its dealings with the third party and should not deal with the claim in any way less favourably than it would have done had the claim been proceeded against its customer.
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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

handbook-rule
An insurer must carry out claims handling promptly and fairly.
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ICOB 7.3.2

handbook-guidance

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. (1) the commercial customer is kept reasonably informed of how his claim is progressing; and
  2. (2) payment is made promptly once settlement terms have been agreed.
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ICOB 7.3.3

handbook-guidance
An insurer should refer to the guidance in SYSC 3.2 (Areas covered by systems and controls) in its procedures for claims handling. For example, an insurer should have in place systems and controls which take account of reasonably foreseeable peaks in demand, to allow it to deal with claims promptly in such circumstances.
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ICOB 7.3.4

handbook-guidance
An insurer should refer to the guidance set out in TC 1 (Commitments) in respect of the competence of any person who carries out claims handling on its behalf.
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Giving customers guidance on claiming

ICOB 7.3.5

handbook-rule
When an insurer is informed that a customer wishes to claim under his policy it must give the customer reasonable guidance to help him make a claim under his policy.
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Rejecting or refusing claims

ICOB 7.3.6

handbook-rule

An insurer must not:

  1. (1) unreasonably reject a claim made by a customer;
  2. (2) except where there is evidence of fraud, refuse to meet a claim made by a retail customer on the grounds:
    1. (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;
    2. (b) of misrepresentation of a fact material to the risk, unless the misrepresentation is negligent;
    3. (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
    4. (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:
      1. (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
      2. (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

handbook-rule
ICOB 7.4 applies to an insurance intermediary.
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ICOB 7.4.2

handbook-guidance
ICOB 7.4 will usually apply to an insurance intermediary that is not an insurer, but it may also apply to an insurer, for example, if it were dealing with a claim on a policy insured by another insurance undertaking.
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An insurance intermediary's duty of care, skill and diligence

ICOB 7.4.3

handbook-rule
An insurance intermediary, when acting for a customer in relation to a claim, must act with due care, skill and diligence.
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ICOB 7.4.4

handbook-guidance
The rules and guidance in ICOB 7.4 do not seek to set out the full extent of the duties owed by the insurance intermediary to any person for whom it acts, nor do they displace the general law on the duties of an insurance intermediary.
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An insurance intermediary's duty to avoid conflicts of interest

ICOB 7.4.5

handbook-rule
  1. (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:
    1. (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
    2. (b) it has obtained the prior informed consent of the customer.
  2. (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

handbook-guidance
ICOB 7.4.5 R imposes a requirement on an insurance intermediary to avoid conflicts of interest in relation to claims where it acts on behalf of a customer, unless it can manage them by disclosure to, and the obtaining of consent from, its customer.
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ICOB 7.4.7

handbook-guidance
An insurance intermediary should consider whether it is possible to manage the conflict by disclosing the conflict to the customer and obtaining his consent. Where an insurance intermediary acts for a customer in arranging a policy, it is likely to be the agent for that customer and any other customers who are policyholders under that policy in connection with the preparation and handling of any claim against the insurance undertaking. If the insurance intermediary intends to be the agent of an insurance undertaking in relation to claims under that policy, it will need to consider whether it is at risk of putting itself in the position where it cannot act without some breach of duty either to the insurance undertaking or the customer making the claim. The insurance intermediary should consider whether disclosure and consent are sufficient to reconcile the conflicting obligations. An example of a circumstance in which disclosure and consent are unlikely to be sufficient, and when an insurance intermediary may well consider that it should not act for the insurance undertaking or the customer (or both), is where the insurance intermediary knows that its customer will, to obtain a quick payment, accept a low amount in settlement of a claim and also knows the insurance undertaking is willing to settle for a higher amount.
  • 06/03/2006

Other notifications and actions in relation to claims

ICOB 7.4.8

handbook-rule
If an insurance intermediary acts for an insurance undertaking and not a customer in relation to a claim on a contract which it arranged, the insurance intermediary must inform the customer that, in relation to that claim, it is acting on behalf of the insurance undertaking, and not the customer.
  • 06/03/2006

ICOB 7.4.9

handbook-guidance
ICOB 7.4.8 R would apply, for example, where an insurance intermediary has delegated authority for claims handling and deals with a claim in relation to a contract that it sold to a customer, if the insurance intermediary is not acting on behalf of that customer in relation to the claim.
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ICOB 7.4.10

handbook-rule

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. (1) forward the notification to the insurance undertaking promptly; or
  2. (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

handbook-rule
An insurer must respond promptly to a notification by a retail customer of a claim.
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ICOB 7.5.2

handbook-guidance
Notification of a claim is a demand of the insurer to pay or provide a benefit insured under the policy, e.g. by submitting a claim form or giving the equivalent information orally, where permitted by the policy. An enquiry that precedes such a demand, for example, as to whether a particular loss is covered, and therefore whether a claim could be made under the terms of the policy, is not notification of a claim.
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ICOB 7.5.3

handbook-guidance
ICOB 7.5.1 R requires an insurer to respond promptly once it has received notification of a claim. Generally a prompt response would be one within five business days of a retail customer making a claim, although in some circumstances, a prompt response could be less than five business days, such as where the retail customer would expect a swifter response because of the nature of the claim or the terms of the policy (for example, a roadside assistance policy).
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ICOB 7.5.4

handbook-rule

The response referred to in ICOB 7.5.1 R must:

  1. (1) provide the information set out in ICOB 7.5.5 R;
  2. (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. (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

handbook-rule

The information referred to in ICOB 7.5.4 R(1) is:

  1. (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. (2) the action that will be taken by the insurer, and when that action will be taken;
  3. (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):
    1. (a) its name (unless the other party trades under the name of the insurer);
    2. (b) its function; and
    3. (c) the work it will carry out in relation to the claim.
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ICOB 7.5.6

handbook-guidance
The purpose of the rules and guidance in ICOB 7.5.1 R to ICOB 7.5.5 R is to provide the retail customer at an early stage with information in relation to the processing and settlement of his claim by the insurer. ICOB 7.5.5 R(1) is intended to prevent a retail customer pursuing a claim for which he is clearly not covered, for example, making a claim on a contents insurance policy for possessions away from home, when the policy only covers possessions in the home. It is not intended to pre-empt the outcome of an investigation of a claim.
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ICOB 7.5.7

handbook-guidance
The purpose of ICOB 7.5.5 R(3) is to ensure that a retail customer knows the name and function of any party who will contact him in relation to a claim as a representative of the insurer e.g. an outsourced claims handling company or a loss adjuster. An insurer would not be expected to notify the retail customer of other parties who are appointed to investigate the validity of a claim, if this would limit or prevent an effective investigation. However, if a third party such as a loss adjuster is appointed to liaise with the retail customer on the insurer's behalf, as well as assess the validity of the claim, the insurer would be expected to disclose the information in ICOB 7.5.5 R(3) unless it would limit or prevent an effective investigation.
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Investigation and processing of the claim

ICOB 7.5.8

handbook-rule
An insurer must keep the retail customer reasonably informed about the progress of his claim.
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ICOB 7.5.9

handbook-guidance
Where the investigation of a claim is likely to be protracted, an insurer should provide periodic progress or status reports, when appropriate, to a retail customer, including providing the retail customer with any relevant update in relation to the information provided under ICOB 7.5.5 R. The insurer should also respond without undue delay to any reasonable request by the retail customer for information.
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Determining the claim

ICOB 7.5.10

handbook-rule

An insurer must notify the retail customer as soon as practicable whether it:

  1. (1) rejects all of his claim;
  2. (2) rejects his claim but, without prejudice to the rejection, makes an offer in compromise; or
  3. (3) accepts all or part of his claim.
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ICOB 7.5.11

handbook-rule
If the insurer rejects the claim, but without prejudice to the rejection makes an offer in compromise, it must notify the retail customer of the terms of that offer as soon as practicable.
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ICOB 7.5.12

handbook-rule

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. (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. (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

handbook-rule
  1. (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. (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

handbook-guidance
Motor vehicle liability insurers should refer to the rules and guidance at ICOB 7.6.8 R to ICOB 7.6.11 G in respect of a claim for damages by an injured party in the circumstances set out in ICOB 7.6.11 G (1).
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ICOB 7.5.15

handbook-rule
The insurer must, in respect of each part of the claim that it accepts, inform the retail customer whether the claim will be settled by paying him, or by paying another person to provide goods or services, or by providing those goods or services.
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ICOB 7.5.16

handbook-guidance
Examples of a payment to others for the provision of goods or services are: to a garage for repairs carried out to a vehicle, to a supplier for the provision of replacement electrical goods, or to a doctor for medical treatment.
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Settling a claim

ICOB 7.5.17

handbook-rule
An insurer must settle a claim by a retail customer promptly.
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ICOB 7.5.18

handbook-guidance
  1. (1) Settlement terms are agreed when:
    1. (a) the insurer accepts the retail customer's claim; and
    2. (b) the retail customer accepts the insurer's offer of settlement.
  2. (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. (3) The guidance in (2) would not apply if the non-investment insurance contract otherwise provides, or the insurer settles the claim by:
    1. (a) payment against a liability due on a future date;
    2. (b) the provision of goods or services;
    3. (c) making payments on a date specified by the retail customer; or
    4. (d) payment of the claim through an employer or other party on a monthly or some other basis;
  4. 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

handbook-guidance
The arrangements for settlement set out in ICOB 7.5.18 G(3)(a) are likely to apply, for example, when payments are made under a creditor insurance policy to meet periodic repayments due under a loan agreement.
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ICOB 7.5.20

handbook-guidance
The arrangements for settlement set out in ICOB 7.5.18 G(3)(b) apply to arrangements to supply goods or services to the retail customer. In such situations, the goods or services should be provided promptly, but where they cannot be the insurer should tell the retail customer when to expect them.
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ICOB 7.5.21

handbook-guidance
An insurer should note that unless it has previously informed a retail customer that a claim will not be met in full or in part until premiums have been paid, the insurer may not delay payment of a claim on the grounds that premiums are outstanding.
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Pre-action protocols

ICOB 7.5.22

handbook-guidance
A customer who does not accept an insurer's rejection of his claim (or part of it) may challenge that rejection. If he chooses to do so through the courts, firms should be aware that in England and Wales there are pre-action protocols which lay down certain requirements as to the steps to be taken before proceedings are issued. This chapter does not displace these requirements, to which firms should have regard in the event that a rejection of a claim moves towards litigation.
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ICOB 7.6

Motor vehicle liability insurers: claims representatives

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ICOB 7.6.1

handbook-guidance
  1. (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. (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

handbook-rule
The Society must ensure that no member carries on motor vehicle liability insurance business at Lloyd's unless a claims representative has been appointed to act for that member in each EEA State other than the United Kingdom, with responsibility for handling and settling claims arising from an accident in the cases referred to in Article 1 of the Fourth Motor Insurance Directive.
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ICOB 7.6.3

handbook-rule
  1. (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. (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

handbook-rule

A motor vehicle liability insurer must ensure that each claims representative is:

  1. (1) resident or established in the EEA State for which it is appointed;
  2. (2) capable of examining cases in the official language or languages of the EEA State of residence of the injured party;
  3. (3) responsible for, and has sufficient delegated authority from the motor vehicle liability insurer for which it is appointed, to be able to:
    1. (a) handle and settle;
    2. (b) collect all information, and take all measures, reasonably necessary to negotiate a settlement of; and
    3. (c) represent, or arrange appropriate representation for, the motor vehicle liability insurer (whether in negotiations, in court or otherwise) in relation to;
  4. 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

handbook-guidance
ICOB 7.6.4 R(3) does not prevent a claims representative from seeking additional authority or instructions from a motor vehicle liability insurer, if its existing authority or instructions are insufficient to allow it to handle and settle a claim. However, it does prevent a claims representative from purporting to decline to deal with, or transfer responsibility for, claims properly referred to that claims representative by an injured party, or an injured party's representative.
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ICOB 7.6.6

handbook-guidance

Nothing in the rules and guidance at ICOB 7.6 prevents, or is intended to prevent:

  1. (1) a motor vehicle liability insurer from appointing more than one claims representative in one, or more than one, EEA State; or
  2. (2) a claims representative from acting for more than one insurer or member; or
  3. (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

handbook-guidance
The appointment of a claims representative does not in itself constitute the opening of a branch or the creation of an establishment (see article 4(8) of the Fourth Motor Insurance Directive).
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Motor vehicle liability insurers: claims handling

ICOB 7.6.8

handbook-rule
  1. (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):
    1. (a) make a reasoned offer of settlement if liability is admitted and damages have been fully quantified; or
    2. (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. (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. (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. (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

handbook-rule
  1. (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. (2) If (1) applies, the amount of interest that the motor vehicle liability insurer must pay must be calculated as follows:
    1. (a) the interest calculation period begins three months after:
      1. (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
      2. (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
      3. (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
    2. (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;
    3. (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

handbook-rule
A motor vehicle liability insurer will be taken to have received a claim, or a fully quantified claim, for damages when that claim, or fully quantified claim, for damages is delivered to the motor vehicle liability insurer, or a claims representative, by any person by any method of delivery which is lawful in the motor vehicle liability insurer's, or its claims representative's, respective State of residence or establishment.
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ICOB 7.6.11

handbook-guidance
  1. (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. (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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ICOB 7.7.1

handbook-rule

An insurer must make and retain for the duration of the claim and for a minimum of three years after it has been settled or rejected, the following information in relation to each claim made against a policy issued by it or handled by it:

  1. (1) details of the claim;
  2. (2) the date the claim was settled or rejected and details of settlement or rejection including information relevant to the basis for the settlement or rejection.
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