Claims Practices. The Company is responsible for the investigating, contesting, compromising or litigating any Reinsured Policy claims in accordance with applicable law and policy terms. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim. The Company acknowledges that it follows industry standard and investigates claims with any of the following criteria:
a) If the claim occurs within the contestable period as defined by the Reinsured Policy; or
b) If there is a reasonable question regarding the validity of the insured’s death or the authenticity of the proofs of death; or
c) If the death occurs outside the United States or Canada; or
d) If the insured is missing or presumed dead; or
e) If there is a reasonable suspicion of fraud. A claim investigation generally includes confirming proof of death, medical records to validate the insured’s medical disclosures and, if material, financial condition at the time of Policy application. Investigations may also include obtaining police reports, coroner’s reports, financial records, or other information that would be appropriate under the circumstances. The Company acknowledges that it does defend against claims meeting the following criteria:
f) If a material misrepresentation is found in the Policy application; or
g) If fraud is found; or
h) If there is insufficient proof of death.
Claims Practices. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim; however, the Company is responsible for investigating, contesting, compromising or litigating Reinsured Policy claims in accordance with applicable law and policy terms. The Company acknowledges that it obtains certified death certificates for death claims, and follows industry standard and investigates claims with any of the following criteria:
a) If the claim occurs within the contestable period as defined by the Reinsured Policy; or
b) If there is a reasonable question regarding the validity of the insured’s death or the authenticity of the proofs of death; or
c) If the death occurs outside the United States or Canada; or
d) If the insured is missing or presumed dead; or
e) If there is a reasonable suspicion of fraud. A claim investigation generally includes confirming proof of death, medical records to validate the insured’s medical disclosures and, if material, financial condition at the time of Policy application. Investigations may also include obtaining police reports, coroner’s reports, financial records, or other information that would be appropriate under the circumstances. The Company acknowledges that it does defend against claims meeting the following criteria:
f) If a material misrepresentation is found in the Policy application and the policy is within the contestable period; or
g) If fraud is found and there is a legal remedy available; or
h) If there is insufficient proof of death.
Claims Practices. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim; however, the Company is responsible for investigating, contesting, compromising or litigating Reinsured Policy claims in accordance with applicable law and policy terms. The Company acknowledges that it obtains a certified death certificate to the extent one exists, otherwise such other documentation as may be agreed to by the Reinsurer for that particular death claim to ascertain the fact, time, and manner of an insured’s death, and follows industry standard and investigates claims with any of the following criteria:
a) If the claim occurs within the contestable period as defined by the Reinsured Policy; or
b) If there is a reasonable question regarding the validity of the insured’s death or the authenticity of the proofs of death; or
c) If the death occurs outside the United States or Canada; or
d) If the insured is missing or presumed dead; or
e) If there is a reasonable suspicion of fraud. A claim investigation generally includes confirming proof of death, medical records to validate the insured’s medical disclosures and, if material, financial condition at the time of Policy application. Investigations may also include obtaining police reports, coroner’s reports, financial records, or other information that would be appropriate under the circumstances. The Company acknowledges that it does defend against claims meeting the following criteria:
f) If a material misrepresentation is found in the Policy application and the policy is within the contestable period; or
g) If fraud is found and there is a legal remedy available; or
h) If there is insufficient proof of death.
Claims Practices. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim; however, the Company is responsible for investigating, contesting, compromising or litigating Reinsured Policy claims in accordance with applicable law and policy terms. The Company acknowledges that it obtains certified death certificates for death claims.
Claims Practices. The Company is responsible for the investigating, contesting, compromising or litigating any Reinsured Policy claims in accordance with applicable law and policy terms. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim. The Company acknowledges that it follows industry standard and investigates claims with any of the following criteria:
Claims Practices. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim; however, the Company is responsible for investigating, contesting, compromising or litigating Reinsured Policy claims in accordance with applicable law and policy terms. The Company acknowledges that it obtains certified death certificates for death claims unless otherwise agreed to by the reinsurer, and follows industry standard and investigates claims with any of the following criteria:
a) If there is a reasonable question regarding the validity of the insured’s death or the authenticity of the proofs of death; or
b) If the death occurs outside the United States or Canada; or
c) If the insured is missing or presumed dead; or
d) If there is a reasonable suspicion of fraud. A claim investigation generally includes confirming proof of death and financial condition, if material, at the time of Policy application. Investigations may also include obtaining police reports, coroner’s reports, financial records, or other information that would be appropriate under the circumstances. The Company acknowledges that it does defend against claims meeting the following criteria:
e) If fraud is found and there is a legal remedy available; or
f) If there is insufficient proof of death.
Claims Practices. It is the Company’s sole decision to determine whether to investigate, contest, compromise or litigate a claim; however, the Company is responsible for investigating, contesting, compromising or litigating Reinsured Policy claims in accordance with applicable law and policy terms. I478580US-13 (06-01-2013) Stand-alone ADB (QT #06635US13) The Company acknowledges that it obtains certified death certificates for death claims, and follows industry standard and investigates claims with any of the following criteria:
a) If the claim occurs within the contestable period as defined by the Reinsured Policy; or
b) If there is a reasonable question regarding the validity of the insured’s death or the authenticity of the proofs of death; or
c) If the death occurs outside the United States or Canada; or
d) If the insured is missing or presumed dead; or
e) If there is a reasonable suspicion of fraud. A claim investigation generally includes confirming proof of death, medical records to validate the insured’s medical disclosures and, if material, financial condition at the time of Policy application. Investigations may also include obtaining police reports, coroner’s reports, financial records, or other information that would be appropriate under the circumstances. The Company acknowledges that it does defend against claims meeting the following criteria:
f) If a material misrepresentation is found in the Policy application and the policy is within the contestable period; or
g) If fraud is found and there is a legal remedy available; or
h) If there is insufficient proof of death; or
i) If the death does not qualify for accidental death benefits and a claim for such benefits has been made.
Claims Practices. The Company acknowledges that it obtains a death certificate or other reliable proof of death for death claims.
Claims Practices. It is the Company's sole decision to determine whether to investigate, contest, compromise or litigate a claim; however, the Company is responsible for investigating, contesting, compromising or litigating Reinsured Policy claims in accordance with applicable law and policy terms. The Company acknowledges that it follows industry standards and investigates claims with any of the following criteria:
a) If the claim occurs within the contestable period as defined by the Reinsured Policy; Or
b) If there is a reasonable question regarding the validity of the insured's death or the authenticity of the proofs of death; or
c) If the death occurs outside the United States or Canada; or
d) If the insured is missing or presumed dead; or
e) If there is a reasonable suspicion of fraud.
Claims Practices. (a) The Reinsured shall notify Reinsurer of any material changes that the Reinsured makes to its claims handling practices after January 1, 2017, including claims staffing models, which impact the Covered Business, which notice shall include an explanation of the rationale for such changes (the “Change Notice”). If the Reinsured changes its claims practices or, without a formal change, engages in a pattern of claims practices having, in the aggregate, the effect of such a change, in a manner that Reinsurer determines has had a material adverse effect on Reinsurer’s Liability or the attachment of Reinsurer’s Liability, including, without limitation, because of a material difference in the claims operation for the Covered Business as compared to the long-tail commercial business not covered (i.e., accident years 2016 and later), the Reinsurer must raise any such determination promptly after its discovery thereof. If the Reinsured agrees, the Parties will work together in good faith to modify such change to the practices.
(b) If the Parties, acting in good faith, are unable to agree with respect to whether there has been a material adverse change in claims practices or whether and how a corrective change shall be implemented or to the impact of such changes, then the Reinsurer must notice a Dispute pursuant to Article XIII hereof, and the procedures set forth in Section 5.4(d) regarding burden of proof and specificity of findings shall apply to any ensuing arbitration. Any such arbitration must be commenced within thirty-six (36) months following the Reinsurer’s receipt of the Change Notice relating to the disputed claims practice.
(c) To the extent that the panel determines that there was a material change to the claims handling practices and that the change did cause a material adverse effect to Reinsurer’s Liability or the attachment thereof, then the panel shall be authorized to adjust the calculation of Ultimate Net Loss under this Reinsurance Agreement, with the Reinsured bearing the difference at its Own Expense, to put the Reinsurer in substantially the same economic position it would have been in had the Reinsured not made the adverse change to its claims practices, and the Reinsured at its Own Expense shall implement in a reasonable time frame and in good faith steps to cure the cause of the material adverse effect that the panel determined the Reinsurer suffered or incurred as a result of such practice, action or inaction.
