Cross strong insurance claims practices rules (2008 Edition)

PICC No. [2008]54

The first section report and claims to accept
One, from the insured or the victims of a report, should be asked about the situation, and immediately inform the insured or the matters related to the specific compensation procedures.
Involving casualties, or accident loss more than cross strong insurance sub limit of indemnity, or a party without insurance accident insurance to pay strong, should remind the parties involved in the accident report to the local traffic management departments to immediately.
A detailed record of two, the insurer shall report the situation, and recorded in the business management system.
Three, the insured motor vehicle traffic accidents, shall be borne by the insured to the insurer for the compensation insurance. The insurer shall, within 1 working days upon receipt of an application for compensation, claim for writing to inform the insured need to provide insurance and compensation of the relevant proofs and materials.
The claim notice must be popular, easy to understand, and according to the actual case check the following and compensation of the relevant proofs and materials:
(1) the claim book, vehicle license, driving license, the insured proof of identity, proof of identity to receive reparations.
(2) the accident proof materials: books, traffic accidents, mediation book (or a simple accident, traffic accident to discuss the agreement, or the court, arbitration, mediation book award, the verdict).
(3) loss to prove: vehicle damage, vehicle repair invoices, loss of property list.
(4) personnel costs prove: the certificate of diagnosis of hospital, medical expenses reimbursement vouchers, prove that delays and income, disability certificate, death certificate, be dependent evidence, proof of residence.
The second section survey and assessment
A motor vehicle accident, the parties of insurance in a client report, responsible party vehicle insurance companies to carry out investigation, the victim's loss was approved. The non defaulting party vehicle relates to casualties compensation, no fault insurance company also should carry out surveying.
An estimated loss of two, more than any one accident compulsory insurance indemnity, should remind the parties for the division of responsibilities according to the law of accident.
Three, the accident involving multiple insurance people, but there are one or more insurers could not surveying cases, failed to carry out surveying insurer, may entrust other insurers to surveying; the entrusted party insurer and the principal underwriter consultation charge certain fees. Entrusted by the insurer, the insured shall submit to the client to provide survey report, accident / loss of picture and by the loss of accident parties signed confirmation.
The third day advance and recovery
A condition, rescue expenses paid in advance
At the same time, meet the following conditions, may pay the rescue expenses.
(a) conforms to the "motor vehicle traffic accident liability compulsory insurance regulations" twenty-second article of the cases;
(two) to advance the traffic control department of the public security organ a notice;
(three) the victim must rescue, and salvage cost has already occurred, rescue hospital rescue bill and the details of the project;
(four) is not by the road traffic accident social rescue fund pays rescue expenses.
Two, advance the standard
(a) in accordance with the traffic accident trauma clinical guidelines and rescue personnel to the national basic medical insurance, the compulsory insurance for medical expenses limit or not responsible for medical expenses limit pays rescue expenses.
(two) the number of rescued treatment in different hospitals in one person and, in medical expenses limit or not responsible for medical expenses limit according to the number of capitation; can also according to the hospital and police advice, as appropriate, within limit adjustment.
Three, pay the way
The traffic police department issued upon receipt of written notification, the advance medical / diagnosis proof, the rescue expenses documents and detailed date, time to rescue the victim commitment issued by the hospital "pays rescue expenses guarantee", or the special account shall be transferred to the rescue cushion payment hospital opened in the bank, no cash payment.
Four, recovery
For all the cases in advance, the insurer has the right to recover the injurer advance. Compensation income after deduction of the legal expenses (costs, legal fees, execution fees), to recover costs, reducing the payment in full.
The fourth section dealing with compensation
One, the principle of compensation
The insurer is liable to indemnify the damage to the victim caused by traffic accident of motor vehicle insurance in insurance liability within the scope of.
Two, the compensation limit
The insurance company insured provide receipt of evidence and information within 5 days from the date of approval, on whether or not to make the insurance liability, and notify the insured; belonging to the insurance liability, and 10 days after the insured reached a compensation insurance agreement, compensation insurance. Does not belong to the insurance liability, it shall make a written explanation.
Three, the rescue expenses paid
For rescuing the victims to the insurer to pay the rescue expenses, the insurer after receiving written notice and medical institutions the traffic administrative department of the public security organs issued by the rescue bill, to pay the rescue expenses. Provisions of the payment standard and payment according to the practice of third section two or three of execution.
The traffic accident insurance does not belong to the responsibility or by the road traffic accident social rescue fund pays rescue expenses will be paid, the insurer is not.
Four, reparations computation
(a) the basic calculation formula
The insured in the insurance to pay strong partial compensation within the limit, respectively to calculate the compensation for victims death and disability costs, medical expenses, loss of property:
1 of the total loss = ∑ partial loss amount = death disability claims and medical expenses claims + property damage claims
2 partial loss amount = amount approved sub losses, i.e.:
Death and disability expenses claims = death and disability costs amount approved bear
Medical expenses claim = medical expenses amount approved bear
Property damage claims = property loss amount approved bear
3 each approved losses amounting to more than cross strong insurance sub limit of indemnity, partial loss amount is equal to the cross strong insurance sub limit of indemnity.
Note: the "victim" for the insured motor vehicle of the victim, not including the insured motor vehicle the car personnel, the insured, hereinafter the same.
(two) when insurance accident involving multiple victims
The corresponding project 1 basic formula is represented as a:
Partial loss amount = ∑ each victim each approved losses amount, i.e.:
Death and disability claims = ∑ each victim cost death and disability costs amount approved bear
Medical expenses claim = ∑ the victims bear medical expenses approved amount
Property damage claims = ∑ the victim property loss amount approved bear
2 of the victims each item approved losses amount and exceed the insured motor vehicle compulsory insurance liability limit of corresponding items, each item loss amount is equal to the cross strong insurance sub limit of indemnity.
3 of the victims each item approved losses amount and exceed the insured motor vehicle compulsory insurance liability limit of the corresponding item, the victim in the insured motor vehicle compulsory insurance liability limit shall be itemized compensation for:
Be partial insurance for motor vehicle compulsory insurance amount of compensation to a victim of partial loss of = a victim cross strong insurance sub limit of indemnity * [in the accident losses amount approved / (sigma each victim item approved losses amount)].
(three) when the insurance accidents involving multi car accident vehicle
1 each of the insured motor vehicle insurance people in their respective cross strong insurance partial compensation within the limit of compensation, calculation of partial loss to the victim.
2 the parties of motor vehicles according to the applicable insurance to pay strong partial compensation limit total partial compensation limit ratio, assessed the partial loss.
A partial loss approved bear amount = item loss amount x [applicable cross strong insurance item limit of indemnity / (sigma the damage caused by the party making the partial compensation limit)]
Note: no responsibility for the accident vehicle in a motor vehicle, not to participate in other non duty vehicles and car property damage compensation calculation, only to participate in duty vehicle loss or car casualties loss compensation calculation.
The non defaulting party on the amount of compensation responsibility for vehicle vehicle loss shall be borne by the responsible party, by the party making no liability for property loss for the next generation.
A full responsibility, not the responsibility of a party, no amount of compensation liability side should bear full responsibility for loss of vehicle for the full responsibility to loss of vehicles, to deliver strong insurance no liability for property loss limit.
A full responsibility, not the responsibility of the parties, no amount of compensation liability side should bear full responsibility for loss of vehicle for the full responsibility to loss of vehicles, to the non defaulting party cross strong insurance no liability for property loss limit and limit.
Many have the responsibility, not the responsibility of one party, the non defaulting party on the amount of compensation for losses shall be borne by the vehicle to deliver strong insurance no liability for property loss limit limit, in the vehicle the average allocation of responsibility.
Many have the responsibility, not the responsibility of the parties, the non defaulting party on the amount of compensation for losses shall be borne by the vehicle to the non defaulting party cross strong insurance no liability for property loss limit and limit, in the vehicle the average allocation of responsibility.
The accident vehicle should be insured and uninsured vehicle, as the insured motor vehicle involved in the calculation.
4 for relevant departments eventually without liability accident, the uniform application of liability limit calculation.
The same amount of motor vehicle 3 accident responsibility and suitable for all vehicles, simplify the partial loss of the average allocation:
(1) for the victims of the motor vehicle, motor vehicle, motor vehicle property loss of personnel:
A partial loss approved bear / item loss amount = victims (N-1)
(2) for the non motor vehicle, the non motor vehicles, pedestrians, vehicles and personnel loss:
A partial loss approved bear N the partial loss amount ÷ amount = victims
Note: ① N for all the motor vehicle accidents in the number of vehicles.
The accident vehicle should be insured and uninsured vehicle, as the insured motor vehicle involved in the calculation.
4 the initial calculation, if the damage caused by the party to pay strong risk limits not compensate enough, while the victim is not fully compensated, the injured party's loss distribution again in cross strong insurance residual limits, fill in the insurance to pay strong limit. For each loss to be allocated together does not exceed the remaining limit of indemnity, compensation distribution according to the results of the parties; exceed the remaining payment limit, according to the amount of each distribution accounted for the total amount of the residual distribution by multiplying the proportion of compensation quota allocation; until the damaged parties are in full amount compensation or payment party should cross strong insurance without the excess amount.
(four) the property loss need rescue, rescue expenses claims and property loss does not exceed the total property damage compensation limit.
(five) the main vehicle and the trailer accident when used in connection with, people cross strong insurance main vehicle and the trailer are liable for compensation in the respective liability limits.
The liability for compensation if the traffic management department not to determine the main vehicle, trailer should bear the main vehicle, trailer, the average allocation to the insurer the partial loss, and calculate the compensation in the corresponding partial compensation limit.
The main vehicle and the trailer by the insured, the traffic accident happened when used in connection with each other, according to the principle of the three.
(six) the insured motor vehicle insurance more than one cross strong insurance, insurance during the period of liability in the insurance contract, in the later period of play does not assume liability to pay compensation.
(seven) comfort on spirit damage the insured in accordance with the court judgment or mediation take gold, in principle, other compensation for the project in full compensation, the compensation for death and disability compensation limit.
(eight) the standard for death and disability costs and the cost of medical care
According to "the Supreme People's court 'scope of compensation, on the relevant issues concerning the application of law in the trial of personal injury compensation case explanation'" items and standards, issued by the Ministry of public security "injured in road traffic accident assessment" (GB18667-2002), as well as the basic medical standard traffic accident personnel trauma clinical guidelines and traffic accident for personal injury compensation amount.
Patients with 1:A, B two motor vehicle traffic accident, two cars have a responsibility. A, B two car loss is 2000 yuan respectively, 5000 yuan, B car, medical staff cost 7000 yuan, death and disability costs 60000 yuan, the other resulting in loss of 1000 yuan. Cross strong insurance property loss compensation limit for two cars is 2000 yuan, amount of compensation for medical expenses for 10000 yuan, death and disability compensation limit for 110000 yuan, then:
(a) A car traffic insurance compensation calculation
A vehicle compulsory insurance compensation amount = dead victim disability indemnity + the medical expenses claims the property and loss compensation
= B car deaths disability approved bear the amount of +B car, medical expenses borne by approved amount + property losses borne amount
1.B car deaths disability approved bear amount = 60000 / (2-1) = 60000 yuan
2.B car, medical expenses approved bear amount = 7000 / (2-1) = 7000 yuan
3 property loss amount approved bear = road property loss amount approved Bear + B car loss amount approved bear
= 1000 / 2+5000 / (2-1) = 5500 yuan, more than the property loss compensation limit, according to the limit of compensation, the compensation amount is 2000 yuan.
Among them, A vehicle compulsory insurance for B car damage indemnity = property damage compensation limit x B car loss amount approved bear / (road property loss amount approved Bear + B car loss amount approved bear)
= 2000 × [5000 / (1000 / 2+5000)] = 1818.18 yuan
Among them, A car insurance to pay strong marketable loss indemnity = property damage compensation limit x road property loss amount approved bear / (path loss amount approved Bear + B car loss amount approved bear)
= 2000 x [(1000 / 2) / (1000 / 2+5000)] = 181.82 yuan
4.A vehicle compulsory insurance indemnity = 60000+7000+2000 = 69000 yuan
(two) B car traffic insurance compensation calculation
B vehicle compulsory insurance compensation amount = road property loss amount approved Bear + A car loss amount approved bear
= 1000 / 2+2000 / (2-1) = 2500 yuan, more than the property loss compensation limit, according to the limit of compensation, the compensation amount is 2000 yuan.
Patients with 2:A, B two motor vehicle traffic accidents, A car full responsibility, B car without responsibility, A, B two car loss is 2000 yuan respectively, 5000 yuan, the other resulting in loss of 1000 yuan. Cross strong insurance property loss compensation limit set for A car is 2000 yuan, the B car is no liability compulsory insurance of property loss limit is 100 yuan, then:
(a) A car traffic insurance compensation calculation
A vehicle compulsory insurance indemnity = B car loss amount approved Bear + road property loss amount approved bear
= 5000+1000 = 6000 yuan, more than the property loss compensation limit, according to the limit of compensation, the compensation amount is 2000 yuan.
(two) B car traffic insurance compensation calculation
B vehicle compulsory insurance indemnity = A car loss amount approved bear
= 2000 yuan, more than no liability for property loss limit, according to the limit of compensation, the compensation amount is 100 yuan.
100 yuan compensation amount B car should bear the loss of A, by A the car insurance in cross strong insurance without responsibility property damage compensation for the next generation.
The fifth section pay indemnity
One, pay reparations
The payment shall be timely upload to the motor vehicle accident liability compulsory insurance information platform. Before the establishment of motor vehicle traffic accident liability compulsory insurance information platform, the insurer to pay the claims should be in the original insurance policy with the "x x months sunrise risks, negative * * (all, mainly, equal, minor) responsibility, * * (no) resulting in death" chapter of the strip.
Two, document segmentation
If the compulsory insurance and commercial three party insurance in different insurance companies, such as the amount of loss more than cross strong insurance liability limit, by cross strong insurance underwriting company retained has compensation cost original invoice or credentials, will need to commercial insurance project original invoice or a copy of the invoice, the insurer claims dedicated seal, hand the insured for commercial insurance claim.
The sixth section directly paid to the victim compensation processing of reparations
An occurrence, bodily injury or property damage, and one of the following conditions are met, the insurer may accept the claim:
(a) the insured issued a written authorization;
(two) the people's court judgment or enforcement;
(three) the death of the insured, missing, loss of ability to escape, claim or written waiver claim rights;
(four) other circumstances stipulated by law.
Two, the claim to the insurer shall provide the following materials:
(a) the people's court judgment or execution of the book, issued or the traffic police department traffic accident responsibility confirmation and reconciliation of book of the original;
(two) the proof of identity;
(three) bodily disability certificate and relevant list of losses and expenses documents;
(four) other and confirm the property of insurance accident, reason, loss and other material relevant to.
By the written authorization of the insurer, the insured shall provide written authorization.
Three, reparations computation
Insurance accident involving multiple victims, in all the victim claim application, also the victim of all materials are submitted, the insurer can be calculated.
(a) the accident victim item all approved loss and within cross strong insurance sub limit of indemnity, compensation calculated according to the actual loss.
(two) the victims each item approved losses amount and exceed the insured motor vehicle compulsory insurance liability limit of the corresponding item, the victim in the insured motor vehicle compulsory insurance liability limit shall be itemized compensation for:
Be partial insurance for motor vehicle compulsory insurance amount of compensation to a victim of partial loss of = a victim cross strong insurance sub limit of indemnity * [in the accident losses amount approved / (sigma each victim item approved losses amount)].
3:A car accident caused two pedestrians a and B, were injured, a medical costs 7500 yuan, 5000 yuan for medical expenses B. Let A cars applies strong insurance to pay for medical expenses limit for 10000 yuan, A vehicle compulsory insurance for a, B loss calculation:
A vehicle compulsory insurance compensation amount = a + B medical expenses, medical expenses
= 75005000 = 12500 yuan, than for strong insurance to pay medical expenses limit of indemnity, compensation 10000 yuan.
A gain cross strong insurance compensation: 10000 × 7500/ (75005000) = 6000 yuan
B received cross strong insurance indemnity: 10000 x 5000/ (75005000) = 4000 yuan
The seventh section closed and archiving
One, the claim documents
The insured person or the victim to pay reparations, will claim all documents are filed according to the claim. The necessary documents including:
(a) a copy of the policy;
(two) report records, insured the written claim;
(three) the survey report, photos and pictures, loss loss project confirmation, medical expenses of the original bills and expenses list, adjustment of claims (above the original bill, by surveying company retained).
(four) driving license and driving license copy, the insured and the victim's identity proof (such as direct payment to the victim);
(five) the accident issued by legitimate traffic management departments of public security organs or institutions such as courts of the proof, the relevant legal documents and other evidence, the parties to negotiate agreement;
(six) the other to confirm the insurance accident, reason of nature, the extent of the loss of the relevant evidence, protocol and written records;
(seven) payment receipt, to receive reparations authorization.
Two, the full amount in advance the case processing mechanism
(a) conditions
Meet the following conditions, which belongs to the liability to pay compensation for the accident:
The 1 relates to casualties, the medical expenditure has exceeded strong insurance to pay for medical expenses limit or estimated cost significantly more than death and disability insurance to pay strong limit for death and disability compensation;
2 the insured to apply and provide the necessary documents.
(two) the basic principles
For the accident casualties, the amount of loss exceeds the insured vehicle is obviously strong insurance to pay for medical expenses limit or death and disability compensation limit, the insurance company can according to the insured's application and relevant documents, in cross strong insurance limits to compensation case, determine the amount of loss to be disposed of after the accident,, the remaining portion of the commercial insurance compensation.
Including the relevant certification materials:
The 1 claim book, vehicle license, driving license, the insured proof of identity, proof of identity to receive reparations;
The 2 book that the responsibility of traffic accident;
3 personnel costs prove: the certificate of diagnosis of hospital, medical expenses reimbursement vouchers; death certificate, proof of dependency.
(three) the basic flow
1 the proposed insured claims.
2 is to provide the necessary documents to the insurer.
3 the insurance company audits in the receipt of the claim application and relevant documents, according to existing materials to determine the amount of compensation than the medical expenses or death and disability allowance cases, by the medical audit staff signed opinions, within 5 days prior to the payment of indemnity. No longer involved in cross strong insurance coverage, the insurance to pay strong case processing.