Rights & Responsibilities of an Insurance Policyholder and/or Prospective Policyholder

How does insurance work? Insurance is an agreement between you and an insurance company whereby the latter guarantees to compensate you for specified loss, damage, illness or death as the result of an unforeseen event. The insurance company agrees to pay you a fair value if you make a claim and in return you agree to pay your premium to the insurance company. Your premium is the money paid by policyholders to insurance companies in return for insurance coverage. Where can you buy insurance? You can buy insurance: directly from an insurer through an insurance broker; an insurance broker sells insurance to and works on behalf of clients. Unlike insurance agents, insurance brokers are free to place business wherever they can find market for the benefit of the client. through an insurance agent; an insurance agent is a person who sells insurance on behalf of the insurance company. through an insurance subagent; an insurance subagent advertises insurance policies on behalf of insurance companies. They operate like salespersons. Whilst an insurance agent or subagent may be tied to one particular insurer, a broker is not. However, they all receive commission for selling you an insurance policy. Information you must be given by insurance providers Insurance companies, brokers and intermediaries, must give you details about the service they are offering, and inform you of the key facts on the insurance policy they want to sell you. Amongst other things, they should also inform you of the main features and benefits of the insurance, any significant or unusual exclusion in the policy, how long the cover will last and whether you have any cancellation rights. This information will make it easier when choosing an insurance whereby you can compare policies with other insurance companies and thus find the right deal for you. You have the right to: get what you pay for As a policyholder, you have the right by law to be treated fairly and with respect. Your insurer must serve you to the best of its ability. Basically, this means that if you are paying for insurance cover and it is detailed in your policy schedule, you must receive it. be fully informed when purchasing a policy Your insurer is required to offer you financial advice and products that best suit your needs. They must explain all the terms and conditions clearly.

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Insurance companies and intermediaries (insurance agents and brokers) are responsible for offering financial advice to ensure adequate coverage for their clients. The degree of advice will depend on the type of insurance player; insurer, agent or broker. Usually the advice of insurance broker will cover broader areas than the advice of agents. When providing financial advice the following are considered: the risks faced by individuals their means to reduce potential risks the ability of the individual to pay insurance coverage It is important to note that financial advice relates to the insurance proposal under negotiation.

Ask your insurer to explain anything that is unclear or difficult to understand. As it is important for you to know exactly what is, and is not, covered under the policy you are considering. Ask your insurer whether the policy contains a binding arbitration requirement which is a procedure whereby the insurance company and you agree to settle a claim dispute by accepting a decision made by a third party namely an arbitrator, without having to go to court. It is important to receive a careful evaluation of the amount of coverage you need in order to ensure that adequate cover is purchased underinsured. When you are underinsured, your insurance cover is inadequate compared to the risks you face. Having inadequate insurance covers means that you will not be covered for certain types of risks you are exposed to under your existing insurance policy and in the event of a claim, you will not be able to recover any financial losses from the insurance policy in relation to these risks. confirm information submitted for an insurance application You should always read and confirm the accuracy of the insurance application yourself. You can request to be shown a copy of the policy before you purchase it and be advised on all excesses, which is the first amount payable by you in the event of a loss, if any is applied. If the person you are talking to cannot answer your questions, or makes you feel that you are being difficult by asking questions, you can ask to speak to another insurance officer or their supervisor. It is your responsibility to read your policy documents, check that the information you have supplied is accurate and inform your insurer if any details need to be changed. If the language of your policy document is confusing or a particular clause is hard to understand, you can and should ask for an explanation. Claims Your rights when making a claim: You have the right to be told specifically about all excesses and limitation provisions, such as the maximum amount you can claim for a specific asset, additional covers or for third party liabilities like injuries, property damage, etc., which are applicable to a claim.

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You can ask for a written explanation for any claims denied or underpayment from the sum insured in your policy. Ask for any policy wordings which are unclear or subject to different interpretations in the policy. If you have made a legitimate claim with your insurer, you can ask that it is thoroughly investigated, promptly evaluated, fairly assessed and fully paid. It is your duty if so requested to inform the Insurer of any information pertaining to any claims or losses suffered previously.

What is Insurance Law? Insurance law is the name given to practices of law surrounding insurance, including insurance policies and claims. It can be broadly broken into three categories - regulation of the business of insurance; regulation of the content of insurance policies, especially with regard to consumer policies; and regulation of claim handling. At common law, the defining concept of a contract of commercial insurance is of a transfer of risk freely negotiated between counterparties of similar bargaining power, equally deserving (or not) of the courts protection. In civil law countries insurance has typically been more closely linked to the protection of the vulnerable, rather than as a device to encourage entrepreneurialism by the spreading of risk. Civil law jurisdictions - in very general terms - tend to regulate the content of the insurance agreement more closely, and more in the favor of the insured, than in common law jurisdictions, where the insurer is rather better protected from the possibility that the risk for which it has accepted a premium may be greater than that for which it had bargained. As a result, most legal systems worldwide apply common-law principles to the adjudication of commercial insurance disputes, whereby it is accepted that the insurer and the insured are more-or-less equal partners in the division of the economic burden of risk. Discussed below are some generally accepted principles of Insurance: Principle1: Principle of Utmost Good Faith: Principle of Utmost Good Faith is the primary principle of insurance. The doctrine of uberrimae fides - utmost good faith - is present in the insurance law of all common law systems. An insurance contract is a contract of utmost good faith. The most important expression of that principle, under the doctrine as it has been interpreted in England, is that the prospective insured must accurately disclose to the insurer everything that he knows and that is or would be material to the reasonable insurer. Something is material if it would influence a prudent insurer in determining whether to write a risk, and if so upon what terms. If the insurer is not told everything material about the risk, or if a material misrepresentation is made, the insurer may avoid (or "rescind") the policy, i.e. the insurer may treat the policy as having been void from inception, returning the premium paid.

In a nutshell, a higher degree of honesty is imposed on an insurance contract than is imposed on other contracts. Honesty is mainly imposed on the insurance applicants. It is supported by three legal doctrines; Representation, Concealment & Warranty. According to this principle, the insurance contract must be signed by both parties (insurer and insured) in an absolute good faith or belief or trust. Both parties in the contract must disclose all material facts for the benefit of each other. False information or non-disclosure of any important fact makes the contract voidable. Principle2: Principle of Insurable Interest: The person getting an insurance policy must have an insurable interest in the property or life insured. A person is said to have an insurable interest in the property if he is benefited by its existence and be prejudiced by its destruction. The presence of insurable interest is a legal requirement. So an insurance contract without the existence of insurable interest is not legally valid and cannot be claimed in a Court. The object of this principle is to prevent insurance from becoming a gambling contract. Most common law jurisdictions require the insured to have an insurable interest in the subject matter of the insurance. An insurable interest is that legal or equitable relationship between the insured and the subject matter of the insurance, separate from the existence of the insurance relationship, by which the insured would be prejudiced by the occurrence of the event insured against, or conversely would take a benefit from its non-occurrence. Insurable interest was long held to be morally necessary in insurance contracts to distinguish them, as enforceable contracts, from unenforceable gambling agreements (binding "in honor" only) and to quell the practice, in the seventeenth and eighteenth centuries, of taking out life policies upon the lives of strangers. In case of life insurance policies, insurable interest must exist at the time of a policy inception, but not at the time of a loss (death). The intent behind this principle is that the insured must be in a position to financially suffer if a loss occurs. This principle helps in preventing gambling by way of taking insurance on a property and waiting for a loss occur. In case of life insurance contracts it reduces moral hazard whereby a person takes life insurance on a person and prays for his/her death for insurance proceeds. Principle3: Principle of Indemnity: The essence of insurance is the principle of indemnity that the person who suffers a financial loss is placed in the same financial position after the loss as before the loss occurred. He neither profits nor is disadvantaged by the loss. In practice, this is much more difficult to achieve in life insurance than in property insurance. No life insurance company would provide insurance in an amount clearly exceeding the estimated economic value of the covered life. Limiting the amount of life insurance sold to reflect economic value gives recognition to the rule of indemnity. Additionally, only persons exposed to the potential loss may legitimately own the insurance covering the insureds life. The principle of indemnity is applicable to all types of insurance policies except life insurance. Indemnity means security, protection and compensation given against damage, loss or injury. The

insurer promise to help the insured in restoring the financial position before loss has occurred. Whenever there is a loss of property, the loss is compensated. The compensation payable and the loss suffered should be measurable in term of money. The insured will be compensated only up to the amount of loss suffered by him. He will not earn profit from the contractor. The maximum amount of compensation will be up to the value of the policy which is fixed at the time of contract. The courts rely upon the principle of indemnity to hold that an insured may not recover more than his true loss. Principle4: Principle of Subrogation: Subrogation means substituting one creditor for another. Principle of Subrogation is an extension and another corollary of the principle of indemnity. It also applies to all contracts of indemnity. According to the principle of subrogation, when the insured is compensated for the losses due to damage to his insured property, then the ownership right of such property shifts to the insurer. It must be clarified here that the insurer's right of subrogation arises only when he has paid for the loss for which he is liable under the policy and this right extend only to the rights and remedies available to the insured in respect of the thing to which the contract of insurance relates. The principle of subrogation is applicable to all insurances other than the life insurance. If the insured party gets a compensation for the loss suffered by him, he cannot claim the same amount of loss from any other party. It prevents the insured being indemnified from two sources in respect of the same loss. Hence this principle of subrogation provided for substitution of the insurer in place of the insured for the purpose of claiming indemnity from a third party wrongdoer for a loss paid by the insurer. This helps in preventing collecting twice by the insured, to hold the negligent party responsible and to bring down insurance rates. Principle5: Principle of Contribution: Sometimes a property is insured with more than one company. The insured cannot claim more than total loss from all the insurance companies put together. He cannot claim the same loss from different insurance companies. If one insurer pays full compensation then that insurer can claim proportionate claim from the other insurers. A person cannot be restored to a better position than before the loss occurred. The total loss suffered by the insured will be contributed by different companies in proportion to the value of policies issued by them. Principle of Contribution is a corollary of the principle of indemnity. It applies to all contracts of indemnity, if the insured has taken out more than one policy on the same subject matter. According to this principle, the insured can claim the compensation only to the extent of actual loss either from all insurers or from any one insurer. If one insurer pays full compensation then that insurer can claim proportionate claim from the other insurers. Principle6: Principle of Proximate Cause: Principle of Proximate Cause means when a loss is caused by more than one causes, the proximate or the nearest or the closest cause should be taken into consideration to decide the liability of the

insurer. This principle is found very useful when the loss occurred due to series of events. The principle states that to find out whether the insurer is liable for the loss or not, the proximate (closest) and not the remote (farthest) must be looked into. However, in case of life insurance, the principle of Proximate Cause does not apply. Whatever may be the reason of death the insurer is liable to pay the amount of insurance. Under this rule, in order to determine whether a loss resulted from a cause covered under an insurance policy, a court looks for the predominant cause which sets into motion the chain of events producing the loss, which may not necessarily be the last event that immediately preceded the loss. Principle7: Principle of Loss Minimization: According to the Principle of Loss Minimization, insured must always try his level best to minimize the loss of his insured property, in case of sudden events like fire etc. The insured must take all necessary steps to control and reduce the losses and to save what is left. This principle makes the insured more careful in respect of this insured property, just as any prudent person would do in those circumstances. If he does not do so, the insurer can avoid the payment of loss attributable to his negligence. But it must be remembered that though the insured is bound to do his best for his insurer, he is, not bound to do so at the risk of his life. The insured must not neglect and behave irresponsibly during such events just because the property is insured. Hence it is a responsibility of the insured to protect his insured property and avoid further losses.

Principles of Insurance : Principles of Insurance Utmost Good Faith Insurable Interest Indemnity Subrogation Contribution Proximate Cause Utmost Good Faith : Utmost Good Faith Good faith- Let the buyer beware Declaration of all material Information about the subject mater of insurance Slide 6:

Material Information is that information which enables the insurer to decide: whether he will accept the risk and; if so, at what rate of premium and subject to what terms and conditions Breach of duty of utmost good faith arises in two ways: Non-disclosure of material facts- oversight, proposer thought its not essential etc. Misrepresentation Intentional. Insurable Interest : Insurable Interest The legal right enjoyed by the owner of a property to insure is called Insurable Interest. The insurance will become null and void, without the insurable interest. Indemnity : Indemnity The principle of Indemnity states that under the policy of insurance, the insured has to be placed after the loss in the same financial position in which he was immediately before the loss. Slide 9: Applicability: When the losses suffered by the insured can be measured in terms of money It is practicable to place the insured in the same financial position which he occupied before the loss In Marine Cargo where valued polices are issued, there is only commercial indemnity- the value declared for insurance is accepted at the time of loss. Limitation of Insurers liability: : Limitation of Insurers liability: If the sum insured is less than the indemnity, only the sum insured is payable. Property insurances- Condition of average- If there is under insurance only proportionate value is payable. Excess/Franchise Exceptions for Indemnity: Personal Accident Subrogation : Subrogation Transfer of rights and remedies from the insured to the insurer who has indemnified the insured in respect of the loss. Contribution : Contribution The right of insurers who have paid a loss under a policy to recover a proportionate amount from other insurers, who are liable for the same loss. Proximate Cause : Proximate Cause The active efficient cause that sets in motion a train of events which brings about a result without intervention of any force started and working actively from a new independent source. Slide 14: Case: A man travelling in a crowded train falls down and gets injured badly. Because of his hurt and bleeding he becomes unconscious and lying by the side of the track. Someone finds him takes him home. He develops fever which ultimately leads to Tetanus and is hospitalised. He is treated in the hospital for ten days then finally he dies! His wife realising he has a personal accident policy makes a claim with the insurance company. Is this claim payable?