Claims Administration Services Clause Samples
The Claims Administration Services clause defines the responsibilities and procedures for managing and processing claims under the agreement. It typically outlines who will handle the receipt, review, and resolution of claims, as well as the timelines and documentation required for each step. For example, a third-party administrator may be designated to oversee claims, or the parties may agree on specific reporting protocols. This clause ensures that claims are handled efficiently and consistently, reducing disputes and providing clarity on the claims process.
Claims Administration Services. If claims services are to be provided pursuant to a particular Service Addendum, then, unless otherwise specifically noted in such Service Addendum, that Service Addendum will be deemed to require the claims administration services set forth in this subsection. Specifically, INSpire will:
(i) investigate, evaluate, and handle each claim reported according to applicable state law, the terms and conditions of the policy and any written standards provided by Customer using appropriately trained and licensed personnel. Customer grants INSpire the authority to provide the foregoing claims administration services; provided, however that INSpire will not have any authority to alter or discharge any policy or waive any policy provision or condition.
(ii) establish a claims operation center that will function as a control unit;
(iii) verify coverage on all cases;
(iv) administer the appraisal/assessment process using a combination of staff, independent appraisers and direct repair facilities reasonably acceptable to Customer;
(v) perform all reasonable and necessary administrative and clerical work in connection with claim or loss reports;
(vi) establish and maintain a claim file for each reported claim or loss. The claim file will have a daily activity log, which will be available for review at any and all reasonable times by Customer subject to the provisions of the Agreement;
(vii) record and report each claim promptly to Customer with a recommended reserve; and will consult with, and seek consent from, Customer with respect to any of the following:
(A) any loss or claim resulting in legal action being instituted against Customer's insured, INSpire or Customer;
(B) any loss or claim causing a complaint to be filed with any regulatory authority;
(C) any inquiry from any regulatory authority, including but not limited to any insurance department, with respect to any claim or claims, even if no complaint causes such inquiry;
(D) any claim in which INSpire deems appropriate to rescind policy coverage for material misrepresentation;
(E) any claim involving an allegation of extra contractual obligations, or bad faith claim handling;
(F) any claim involving a fatality, major amputation, spinal cord or brain damage, loss of eyesight, extensive burn▇, poisoning, or multiple fractures;
(G) any claim that Customer desires to be kept advised of during the life of the claim; or
(H) any claim where there has been a demand for policy limits and INSpire does not evaluate the va...
Claims Administration Services. Claims administration fees for each of the months during the Initial Period will be equal to 6.67% of the Earned Premium recognized by Customer for such month. Claims administration fees for each month subsequent to the Initial Period will be equal to 6.50% of the Earned Premium recognized by Customer for each such month. Effective July 1, 2000, the claim administration fee will be subject to a minimum of $105,000.
Claims Administration Services. Active management of new and legacy claims.
Claims Administration Services. On or before the first day of each month during the Term, the Town will pay Consultant a fixed monthly fee for the claims administration services described in this Agreement. The Town's obligation to pay compensation in future fiscal years shall be contingent upon budget authorization by the Town Council. $4,291.66 monthly FY 2017-18
Claims Administration Services. Servicing Company will handle all self-insured workers compensation claims reported to it by Client during and for the term of this Agreement, or any extension thereof, consistent with the terms of this Agreement and the workers’ compensation laws, rules and regulations of the State of South Dakota. Claims administration services consist of:
a. Conduct a claims investigation as appropriate for each loss in order to establish compensability. In the course of conducting a claims investigation, the services of independent contractors may be retained and paid from the loss fund account as an allocated loss adjustment expense including independent adjustment companies, managed care providers, medical specialists and legal service providers as necessary to determine claim compensability or otherwise assist in properly resolving such claims. Investigations using outside field adjusters may be performed, at the discretion of the claim examiner. 2014 SI ASA
b. Establish individual claim files for each reported claim. Claim files shall be subject to review, copying and printing by Client, its representative or designee, at any reasonable time within normal business hours upon reasonable notice.
c. ▇▇▇▇▇▇, or contract with a third party to assert, any subrogation rights of Client in regard to payments for workers’ compensation benefits. Client will receive any subrogation recoveries obtained by Servicing Company. Services of independent contractors may be incurred by Servicing Company as an allocated loss adjustment expense.
d. Set financial reserves to expected or probable outcomes based on industry best practices, and facts and opinions of experts retained during the claim investigation.
e. Report claims to excess or aggregate reinsurer pursuant to the terms of the Client’s policy.
f. Calculate average weekly wage and wage loss benefits using wage information provided by the Client.
g. Engage nurse case managers, vocational rehabilitation consultants and return to work coordinators as an allocated loss adjustment expense.
h. Perform annual claim reviews.
Claims Administration Services. Administrator will provide the following and such other services as may be considered necessary and which are mutually acceptable to both parties:
(i) Supervise and administer the open claims in compliance with applicable laws, rules and regulations governing the administration of self-insurance programs and imposed by the State of Florida. Claims will be timely adjusted and Administrator will be responsible for penalties if the penalty arises from the neglect of the Administrator.
(ii) Provide qualified and experienced personnel capable of servicing the open claims of the Client. Administrator will maintain an office with toll-free telephone services and experienced employees.
(iii) Complete processing of loss adjustments, investigations and settlements falling within the self-insured retention level. Submissions of all investigation reports, legal actions, court orders, or awards shall be provided to the Client together with recommendations to be taken in the event claims exceed the limits of authority of Administrator. Administrator must obtain prior approval from the Client, for all settlements.
(iv) Coordinate investigations of and manage litigated claims with defense attorneys.
(v) Develop subrogation possibilities and assist in the collection of same. Submit claims to reinsurance/excess carriers and assist in the recovery of such benefits (if any) on behalf of Client.
(vi) In the event of termination of the contract, Administrator shall not have any responsibility or obligation to handle any claims beyond sixty (60) days after the termination date.
Claims Administration Services. Effective January 1, 2000, the claim administration fee will be 7.0% of the Earned Premium recognized by Customer subject to a minimum of $105,000.00 until August 31, 2001 when the minimum monthly fee shall be completely eliminated and no minimum shall be required thereafter.
Claims Administration Services. Claims Administration fees shall be equal to 7.75% of the Earned Premium recognized by the Client for each month. Subject to Section 7.2(d) of the Processing Services Agreement to which this Schedule 1 is a part, CGI will be entitled to retain 25% of all subrogation recoveries and 15% of all salvage recoveries. Special Investigative Unit Services will be provided as approved by Client for the fee of $60 per hour, plus actual expenses.
Claims Administration Services. Prior to January 1, 2000 for all programs and January 1, 2000 and later for any discontinued programs, fees will be based on a charge per claim as defined below. A claim is defined as an open feature as shown below. Monthly maintenance fees are for claims open greater than 31 days at each month end. Customer will not be responsible for any of the fees set forth below that are incurred in connection with a claim opened in error. Feature Claim Fee Monthly Fee Auto BI/UM $450 $100 Auto Non-BI/UM $250 $50 Auto First Party $150 $50 Homeowners $600 $60 Commercial Property $700 $70 Commercial Casualty $1,000 $100 Effective January 1, 2000, all programs other than discontinued programs will be charged at the following rates: Line of Business Percent of Earned Premium Residential Property 7.0% Personal Auto 7.5% Commercial Lines 9.5% Other Fees: ---------- Subrogation 25% of recoveries Salvage 15% of recoveries SIU Services $60.00/hr. plus outside fees Homeowner, Commercial Property and Commercial Casualty claims with an incurred loss greater than $100,000 will be billed at "time and expense," rather than the rates shown on the above schedule. "Time and expense" is defined as $60.00 per hour plus any outside adjusting fees.
Claims Administration Services