Claims Handling Services. Where agreed with us by you, we will provide our claims handling services during the period of our appointment for the policies placed by us. These services can be continued beyond our appointment by mutual agreement and will be subject to a separate fee. Our claims handling services include, upon receiving the required information from you, the notification of the claim or circumstances to insurers, representing you in the resolution of the claim and arranging the collection and/or settlement of the claim in accordance with market practice and your policy terms and conditions. Where claims are to be dealt with by you with insurers directly, we will provide advice and support as requested. We may use third party claims handling services, however, where we intend to do so we shall inform you prior to the inception of the insurance contract. Further, our claims handling services will cease where we are satisfied that you have appointed another broker or adviser to act as your agent. If a loss adjustor is appointed, we shall, with your permission, pass on your contact details and co-ordinate meetings. In the case of a major loss, we can attend the initial meeting with the loss adjustor if you wish us to. We will promptly forward to you all claims documentation, insurance company settlement cheques and other information. If any claims are outstanding when you terminate our appointment as your insurance broker, we will provide details of the claim(s) to your new insurance broker so that they may continue to negotiate settlement on your behalf. Where we collect claims payments, they will be remitted to you as quickly as possible. However, we will not remit claims monies to you before we have received them from insurers.
Claims Handling Services. The Administrative Services shall include, as necessary and appropriate, all functions relating to the handling of A&P Claims, including those functions set forth in this Section 5.1.
(a) Administrator shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each A&P Claim. Administrator shall pay, using its own funds, A&P Claims and associated expenses as Ultimate Net Loss under the LPT Reinsurance Agreement and subject to the terms of the LPT Reinsurance Agreement.
(b) Without limiting paragraph (a) of this Section 5.1, Administrator shall:
(i) establish, maintain and organize A&P Claim files and maintain and organize other A&P Claims-related records;
(ii) review all A&P Claims and determine whether the claimant is eligible for payment and if so, the nature and extent of such payment;
(iii) maintain trained claims personnel;
(iv) maintain a complaint log with respect to the Reinsured Contracts in accordance with applicable requirements of Governmental Authorities and provide a copy of such log upon Reinsureds’ request;
(v) gather all information necessary for Reinsureds to comply with regulatory reporting requirements related to A&P Claims detail, including Medicare Set Aside reporting;
(vi) respond promptly to all written or oral A&P Claims-related communications that Administrator reasonably believes to require a response; and
(vii) in accordance with Articles VII and XI hereof, respond to, or assist Reinsureds’ in responding to, regulatory and legal matters to the extent such matters relate to A&P Claims.
Claims Handling Services. ADMINISTRATOR shall perform the following services:
A. In conjunction with the SCHOOL BOARD, maintain a criteria-based model of workers’ compensation program administration.
B. Prepare and follow service instructions that have been approved by the SCHOOL BOARD in the handling of the SCHOOL BOARD claims and catastrophic claims.
C. Receive, examine and adjust on behalf of the SCHOOL BOARD all reports of employee injury.
D. Provide initial clinical triage supported by predetermined criteria, appropriate deployment of resources including telephonic case management, field case management using staff knowledgeable in the criteria, protocols and appropriate utilization of internal and external medical management resources.
E. Contact injured worker, employer and witnesses, either in writing or orally, within 24 hours of ADMINISTRATOR’s receipt of claim report.
F. Conduct such investigation as in the exercise of professional judgment would seem necessary. Enhanced efforts shall be taken to identify possible fraudulent claims, including recorded statements and discussions from injured workers, witnesses and supervisors.
G. Subject to applicable workers’ compensation law and the exercise of professional judgment, accept and adjust, settle or deny (settlements and denials need prior approval by the SCHOOL BOARD Administrative Agent) each reported claim of employee injury. The final decision to settle or deny shall rest solely with the SCHOOL BOARD.
H. Report claims to SCHOOL BOARD excess insurer(s) in accordance with the requirements of the excess insurer(s) policies.
I. Up to a discretionary limit of $10,000 and subject to the foregoing provisions, review and, if appropriate, pay in a timely fashion; and in conformity with legally imposed medical and surgical fee schedules, network discounts and/or contracted fees, all on- going claims and expenses pertaining thereto. ADMINISTRATOR shall request approval from SCHOOL BOARD Administrative Agent prior to issuance of medical or expense payments in excess of $10,000. The final decision to accept, deny or settle any claims shall rest with the SCHOOL BOARD.
J. Consult with SCHOOL BOARD on the selection and referral to outside professionals such as surveillance personnel, expert witnesses and field adjusters/nurses to assist in the investigation, adjustment and medical management of claims. ADMINISTRATOR will review all bills for such services for reasonableness and conformity to pre-established rates or fees and have the a...
Claims Handling Services. The Administrative Services shall include, as necessary and appropriate, all functions relating to the handling of Subject Claims, including those functions set forth in this Section 5.1.
(a) NICO shall acknowledge, consider, review, investigate, deny, settle, pay or otherwise dispose of each Subject Claim. All payments of Losses, Allocated Loss Adjustment Expenses, and Extra Contractual Obligations in respect of Subject Asbestos Liabilities shall be made in accordance with Section 13.1 hereof.
(b) Without limiting paragraph (a) of this Section 5.1, and subject to Reinsureds providing the services set forth in the Transition Services Agreement, as necessary and appropriate, NICO shall:
(i) establish, maintain and organize Subject Claim files and maintain and organize other Subject Claims-related records;
(ii) review all Subject Claims and determine whether the claimant is eligible for payment and if so, the nature and extent of such payment;
(iii) maintain trained claims personnel;
(iv) maintain a complaint log with respect to the Underlying Policies in accordance with applicable requirements of Governmental Authorities and provide a copy of such log upon the Reinsureds’ request;
(v) subject to Section 8.1 and paragraph (vi) below, provide Reinsureds with such information as is necessary for them to comply with regulatory requirements related to the Subject Asbestos Liabilities;
(vi) provide necessary Medicare Set Aside information as directed by Reinsureds and, subject to receipt of necessary information from Reinsureds, comply on behalf of Reinsureds with Medicare lien requirements, it being understood that NICO shall not be required to report directly to Centers for Medicare and Medicaid Services;
(vii) subject to Section 8.1, respond promptly to all written or oral Subject Claims-related communications that NICO reasonably believes to require a response; and
(viii) in accordance with Articles VIII and XII hereof, respond to, or assist Reinsureds in responding to, regulatory and legal matters to the extent such matters relate to Subject Claims.
