Related provisions for FEES 6.2.2
1 - 20 of 31 items.
1When
an insurer or managing
agent receives a claim under a long-term
care insurance contract, it must respond promptly by providing
the policyholder, or the person acting on the policyholder's behalf,
with:(1) a claim form (if it requires one
to be completed);(2) a summary of its claims handling
procedure; and(3) appropriate information about the
medical criteria that must be met, and any waiting periods that apply, under
the terms of the policy.
As soon as reasonably practicable after
receipt of a claim, the insurer or managing agent must tell the policyholder, or the person acting
on the policyholder's behalf:(1) (for each part of the claim it
accepts), whether the claim will be settled by paying the policyholder,
providing goods or services to the policyholder or
paying another person to provide
those goods or services; and(2) (for each part of the claim it
rejects), why the claim has been rejected and whether any future
An insurer and
a managing agent must not:(1) unreasonably reject a claim; or(2) except where there is evidence
of fraud, reject a claim for:(a) non-disclosure of a fact material
to the risk which the policyholder could
not reasonably have been expected to disclose; or(b) misrepresentation of a fact material
to the risk, unless the misrepresentation is negligent; or(c) breach of warranty, unless the
circumstances of the claim are connected to the breach, the warranty is material
to
Put another way, where an intermediary's assistance in filling in a claims form is material to whether performance takes place of the contractual obligation to notify claims, it is more likely to amount to assisting in the administration and performance of a contract of insurance. Conversely, in the FSA's view, a person who merely gives pointers about how to fill in the claims form or merely supplies information in support of a claim will not be assisting in the performance of
More generally, an example of an activity that, in the FSA's view, is likely to amount to assisting a policyholder in both the administration and the performance of a contract of insurance is notifying a claim under a policy and then providing evidence in support of the claim, or helping negotiate its settlement on the policyholder's behalf. Notifying an insurance undertaking of a claim assists the policyholder in discharging his contractual obligation to do so (assisting in the
Where a person receives funds on behalf of a policyholder in settlement of a claim, in the FSA's view, the act of receipt is likely to amount to assisting in the performance of a contract. By giving valid receipt, the person assists the insurance undertaking to discharge its contractual obligation to provide compensation to the policyholder. He may also be assisting the policyholder to discharge any obligations he may have under the contract to provide valid receipt of funds,
(1) Agency
agreements between insurance intermediaries and insurance undertakings may be of a general
kind and facilitate the introduction of business to the insurance
undertaking. Alternatively, an agency agreement may confer on
the intermediary contractual
authority to commit the insurance undertaking to
risk or authority to settle claims or handle premium refunds
(often referred to as "binding authorities"). CASS 5.2.3 R requires
that binding authorities of this kind must
(1) A firm must not agree to:(a) deal in investments as agent for an insurance undertaking in connection with insurance mediation; or(b) act
as agent for an insurance undertaking for
the purpose of settling claims or handling premium refunds;
or(c) otherwise
receive money as agent of an insurance undertaking;unless:(d) it
has entered into a written agreement with the insurance
undertaking to that effect; and(e) it
is satisfied on reasonable grounds that the terms of the policies
(1) CASS
5.4 permits a firm, which
has adequate resources, systems and controls, to declare a trust on terms
which expressly authorise it, in its capacity as trustee, to make advances
of credit to the firm'sclients. The client
money trust required by CASS
5.4 extends to such debt obligations
which will arise if the firm,
as trustee, makes credit advances, to enable a client's premium obligations
to be met before the premium is
remitted to the firm and similarly
if it allows claims
The deed referred to in CASS 5.4.6 R must
provide that the money (and,
if appropriate, designated investments)
are held:(1) for
the purposes of and on the terms of:(a) CASS
5.4;(b) the
applicable provisions of CASS
5.5; and(c) the client money (insurance) distribution rules(2) subject
to (41), for the clients (other than clients which
are insurance undertakings when
acting as such) 1for whom that money is
held, according to their respective interests in it;(3) after
all valid
Text of article 2.3 of the Insurance Mediation Directive"'Insurance mediation' means the activities of introducing, proposing or carrying out other work preparatory to the conclusion of contracts of insurance, or of concluding such contracts, or of assisting in the administration and performance of such contracts, in particular in the event of a claim.These activities when undertaken by an insurance undertaking or an employee of an insurance undertaking who is acting under the
However, the disaster recovery contracts considered by the FSA had two key features.(1) Priority access to facilities in the event of a disaster was expressed to be on a 'first come, first served' basis. The contracts provided expressly that if the facilities needed by recipient A were already in use, following an earlier invocation by recipient B, the provider's obligation to recipient A was reduced to no more than an obligation of 'best endeavours' to meet A's requirements.
The following are examples of typical warranty schemes operated by motor dealers. Provided that, in each case, the FSA is satisfied that the obligations assumed by the dealer are not significantly more extensive in content, scope or duration that a dealer's usual obligations as to the quality of motor vehicles of that kind, the FSA would not usually classify the contracts embodying these transactions as contracts of insurance.(1) The dealer gives a verbal undertaking to the purchaser
Any breach in the duty of a firm or of its agents under the regulatory system or civil law can give rise to claims being made against the firm. Professional indemnity insurance has an important role to play in helping to finance such claims. In so doing, this chapter amplifies threshold condition 4 (Adequate resources). This threshold condition provides that a firm must have, on a continuing basis, resources that are, in the opinion of the FSA, adequate in relation to the regulated
The contract of professional indemnity insurance must incorporate terms which make provision for:(1) cover in respect of claims for which a firm may be liable as a result of the conduct of itself, its employees and its appointed representatives (acting within the scope of their appointment);(2) the minimum limits of indemnity per year set out in this section;(3) an excess as set out in this section;(4) appropriate cover in respect of legal defence costs;(5) continuous cover in
The purposes of the long-term insurance business include the payment of claims, expenses and liabilities arising from that business, the acquisition of lawful access to fixed assets to be used in that business and the investment of assets. The payment of liabilities may include repaying a loan but only where that loan was incurred for the purpose of the long-term insurance business. The purchase or investment of assets may include an exchange at fair market value of assets (including