Claim Stories

The claim was rejected at first by the insurer. Reason being the injury sustained during the fall while playing volleyball aggravated the injury at the same location, where the student had met with an injury during a skiing incident in year 2019.

The Policy clearly stated that injury caused by skiing incident falls under the exclusion clause.

An appeal was sent to the insurer to have a further examine of the injury. Adjuster was appointed, an appointment arranged to have the student examine by an Orthopedic Consultant.

The appeal was successful and the claim was approved for RM6K++.

1.  Any reason(s) of rejecting a claim must be further scrutinize on its validity & the fairness of rejection.
2. Not just simply and easily of accepting the reason(s) of rejection.
3. It is the insured right to have a fair compensation and treatment.
4. A responsible Agent will always be looking after the insured right and interest.
5. Selection of a qualify agent is very crucial, they play an important role as when claim arises.
6. The School has extended their appreciation to Dindings Corporate Insurance Agency (DCIA) as below: –

The claim was approved on the same day – in ONE Working Day.

The reasons for the fast claim approval: –

1. Immediately report of the claim by the insured;
2. Fast action by the agent to liaise with the insured for the required claim documents;
3. Proper advice and guidance given by the agent on the claim processing;
4. Good working relationship between the agent and the insurance company;

It is important to appoint a professional and knowledgeable agent who is well versed with insurance matters and has strong partnership with the insurance company.

1. The claim was approved for RM648K++
2. Losses for individual house owners were rejected, reason “Personal properties and renovation done by house owners are not covered under the policy”.

Amongst other things, insured should take note of the important of the attending agent: –

1. Quick respond to notify insurer;
2. Immediate action to arrange Adjuster visit on the same day of the incident without delay;
3. Coordination of the claims submission to ensure the full completion of required documentation.
4. Appropriate advice and proper guidance during the entire claims process;
5. Follow-up action on the claims progress at all time;
6. Review the final Claims Offer to ensure it is a fair compensation.

A professional and knowledgeable agent will not only to ease your burden during the claims process, and the most challenging is to speed up the claim approval within the shorter timeline.

The claim was rejected due to below reasons: –

1. Breached of policy general condition as insured did not notified the insurer on the material change in the risk whereby the Main Contractor was terminated and a new contractor was appointed.
2. The loss was not notified to the insurer within 14 days which again had breached the Policy Condition as it had jeopardized the insurer right to mitigate the risk/avoid the recurrence of the lost.
3. The claim had fell within the Exclusion Clause that states “The insurer will not indemnify the insured in respect of loss, damage of liability directly caused by or arising out of aggravated by cessation of work whether total or partial”

Insured should ensure that a proper project management is in placed which should include the followings: –

1. Proper personnel to be employed to manage a project.
2. Roles, duty and responsibility of each personnel in the project team is clearly assigned.
3. Proper channel of reporting with full documentation is a crucial.
4. Timely and frequent updating on the progress of the project, so that any incident could be highlighted and immediate action to be taken.

In addition, insured to appoint a reputable and professional insurance agent to provide proper advice & guidance on their insurance protection.

The water leakage was caused by the bursting water pipes due to aging, wear & tear of the said pipes. The claims for the repair were fully approved. However, the claims by the shop owners or tenants were rejected.

It was clearly stated in the Tenancy Agreement that it is the duty and responsibility of all tenants to have their own insurance coverages for their stocks, renovations, equipment and all assets & contents in their shop respectively.

The buildings fire policy only covered the building structure and fittings and not inclusive of the contents in the individual shop.

The Mall Management Public Liability would not be responsible to third party claim as the tenant had “pre-agreed” in the Tenancy Agreement to be fully responsible for their own property and would not proceed with subrogation claim against the mall management. Therefore, the third party claim is not apparent in this case.

As the tenant or shop owner, it is a MUST to have their own insurance policy protection.

This will provide a clear area of responsibility and duty between both the landlord and tenants.

By doing so, it will also avoid any unnecessary argument or dispute that may arises when incident happened.

At the same time the Tenant shall arrange the protection to protect their own interest. As the loss or damage could come from their owner negligent (property damage claim) and the negligent may cause damage to other tenants as well (3^rd Party claim).

1. A professional Agent that always prepared to help the insured/ claimant especially when there is a claim arises
2. It is the duty of the Agent to negotiate for a timely and fair claim settlement.
3. Lacking in project management skill, may cause the unnecessary damages such as project costs overrun or losses, and delay in completion.

The Adjuster also proposed the “Risk Improvement”: –

 “There is a MUST for the Project Manage or Site Supervisor to conduct daily checking to all floors, and make sure the site conditions are in order before going off.”

Claim was approved for RM20,000++.
Adjuster findings, only 4 units of the 6 units were payable, claim for two units were rejected as both units (2A & 2B) were vacant and fall under the PIAM Revised Fire Tariff general exclusion clause under Section 5, item 7b(a).

i.e. Bursting or overflowing of water tanks apparatus or pipes is under exclusion, as when the building is vacant and unattended for more than 90 days period.

Insured shall always update and inform your agent or insurer for your premise if there are any changes of
1) The business activities/occupations; and
2) Any major extension/renovation.

In order that the needed protection is in place and/or waiver of exclusion has been granted, if necessary.

Tower House Unit 1 (1A – Occupied & 1B – Vacant); consider occupied.

Tower House Unit 2 (2A & 2B – Vacant); consider overall Vacant.

The Adjuster took a little longer time to finalize the claim offer due to: –

1. There was an argument whether there was an “extended coverage” of the subsidence landslip in the policy.
2. The substantial amount of the claim. For higher amount of claim, they need more details investigation.

Adjuster findings: –

For normal subsidence landslip, they only cover the damages to building structure and any build-in infrastructures in the building.

With an “Extended” coverage, it will cover the damages for those infrastructures outside the building but within the boundary (i.e. within/inside the fencing).

The claim was only approved for the repair costs of the water outlet system amounting to RM75,000++.

The replacement of the drainage and the soil enhancement on the surrounding area were NOT payable.

The reasons: –

1. Any enhancement or protection upgrade is not cover under the policy.
2. The ownership of the drainage was under the Authority not part of the condo or insured building.

1. The Subsidence Landslip perils must be extended with Deletion (A) clause, in order to include the coverage for the infrastructures outside the building but within the fencing.
2. In this case if without the extended coverage the claim will be fully rejected. The repair costs for the water outlet would not be payable, as it was located outside the building.
3. Getting a proper advice is crucial for a comprehensive insurance coverage.

Claim approved within 45 days with final offer of RM117,000++.

Adjuster findings, the installed equipment was heavy and large, and the theft incident may not be happening in one (1) day.  It could be 2 incidents or more.

How to have a speedy claim approval even with substantial claim amount?

1. The Insured’s Role:-

• Fast action of notification;
• Full corporation with Adjuster;
• Submission of Claim Form & required documentation without delay

2. The Agent’s Duty:-

• Professional advice;
• Closely monitoring & following-up the claim process;
• A Star Club Qualifier by having the “Fast Track Claim” privilege treatment from insurance company.
• Strong relationship with insurance company

The claim was approved and paid within 2 weeks period.

1. Fast and accurate advice from an insurance agent is important especially during claim.
2. The 3^rd Party Vehicle claim might be drag to 3-6 months for the settlement.
3. And for a straight forward own damage claim can be settled within 14 working days.
4. When comes to selection of Insurance Agent, make sure they are reputable and professional.

There was not negligence or wrong doing of the JMB that caused of the damages. In fact, it was the dog owner who was negligence in not able to manage and control the dog that resulted in the tuition teacher been bitten.

The Claims was rejected.
Any claims toward the liability policy, it must be a proof of wrongful act or negligence by the JMB.
The visitor (tuition teacher) may seek for the dog owner for Personal Liability.

Refer to the Error & Omission coverage terms: –
Firstly, there should be a proof of any “Wrongful Act” by the JMB. However, in this case there was none.

In addition, under the definition of loss it does not covers for legal costs in defend, as when the JMB is not liable.
The extract from the policy jacket: –

The Claims was rejected.

Majority of the Liability policy does not cover for legal fees. There are two versions of coverage terms provided by the insurers in the market, one with the inclusive of legal costs for defend, and the other is not. Of course, with the inclusion, the premium charged will be higher.

It was a clear-cut case that the policy is liable for the damages and the claims is payable. And more time taken to finalize due to the substantial claims submitted early.

The Claims was approved with the final amount of RM271K++.

1. It is not advisable to have only “One” quotation from a single supplier. To get few quotations for comparison and seek advices from different suppliers.
2. It is the insured responsibility to review and negotiate before submitting the claims to insurance company.
3. The bigger value of claims or damages will trigger more details of investigation.
4. Additional expert’s view is needed to arrive on a fair compensation and also for statutory compliance purposes.
5. Time needed to let those relevant experts to come out with their findings and report.
6. The insurer needs longer time to finalize the claims and it may cause delay.
7. The condo residents are the victim for more longer inconvenience period, without a proper working lift for their daily activity.

As per stated in the current condo policy, all residents together with the JMB was named as the insured or the owner of the policy. Therefore, as the owner of the policy, the resident is not entitled to make any claim under their own public liability policy.

The claim was rejected with the reason that it is no logical sense for the owner of a policy to claim for their own Public Liability. The Public Liability policy is to protect the insured for damages or bodily injury claim from a third party.
We are not convinced and happy with the outcome and decided to further appeal on this case.

After looked into the details, we found out that it was an “error” in the policy issued. There are two parts of coverages under the normal condo policy packages: –
– Part 1 is for the building fire and;
– Part 2 is the miscellaneous classes which more relevant to the daily operations of the JMB, such as burglary/theft, equipment all risk, petty cash, error and omission, others and public liability is included under this section.

Because of the insurer “condo promotion package”, the policy has been named as one.
Under the normal circumstances if without the promotion, there will be two separate named section i.e. Part 1 is named under all residents and JMB; Part 2 is named under the JMB only.

In view of the above, we submitted an appeal on the JMB behalf based on the above findings. Finally, the insurer accepted and agreed with our argument, and the claims was approved.

Please do check and make sure your condo policy is named under two separate sessions: –

Part 1 (Building Fire) – named under all residents together with JMB;
Part 2 (Misc. classes) – the JMB alone is the insured or named owner.

Since the origin of object could not be verified it was confirmed as not a part of the condo property and does not belongs to the condo. Hence no evidence of wrongful act by the Management and the insurance policy was not liable for the compensation.

The claim was rejected. It was obvious that there was no negligence by the Condo Management.

However, we managed to appeal successfully on behalf of the Management. Basing on our strong relationship with the insurer and on the ground of humanity, the insurer agreed with our proposal to pay. This was a genuine case as the student was really suffering due to the injury. Moreover, it was an honest claim, the student only submitted for his medical bills together with the spectacle replacement cost. It was a fair claim and the amount was reasonable.

The incident was classified as ”Act of God” as it was beyond the control of the Management. Hence the claim under Public Liability was not payable but due to the strong relationship between the serving agent and the insurer the claim was finally paid.

The lost was confirmed cover under the policy. The claims were payable.

First Building;
Total claims = RM150K++
Claim approved = RM50K, as per the sum insured on first loss basis.

Second Building:
Total Claims = RM80K++
Claim approved and paid full. Sum insured @RM100K on first loss basis.

• It is important to review and to make sure the sum insured is adequate.
• Don’t ever just pick and follow the sum insured as per the standard packages offered by the insurer.
• The service quality of the security company must possess a reasonable level of standard.
• If possible, the security company must have their “Error and Omission or Public Liability” policy in place.
• To take serious measure such as make sure the generator room is locked at all the time.
• And also, there will be compulsory routine check by the security guard too.
• Additional risk measurement: –

1. To install a CCTV at the entrance of the generator room; and
2. To install an alarm system to the door.

There were no evidence to show that Mall Management was negligence or did any wrongful act. No toilet cleaning activity was held during the time of accident, if there was then the management would be blamed for not displaying the caution signage “wet floor” at the toilet entrance.

Moreover, everyone has a responsibility for their own safety when using the public toilet, knowing that the toilet floor could not be dry all the times.

Based on the adjuster finding and the policy’s wording, the claim was not payable.

However, the serving agent took into consideration of the following: –

1. Mall business reputation and to avoid unnecessary retaliation that could affect the businesses;
2. On humanity ground that she did suffered pain due to the injury;
3. Her honesty to claim only for her medical bills;
4. The strong relationship between the servicing agent and the insurer.

The insurer approved the claim for her medical bills.

It is important to choose a right candidate as your Insurance Agent who would assist you when needed especially during claim. The agent relationship with the insurer is also a critical path in deciding the claim outcome.

Upon submission of the full set of claim documents to the insurer on 7 April 2020, time 2.10pm, the claim was approved and Settlement Letter received from the insurer same day, time 5.10pm (3 hours later).

How to speed up the claim processing: –
1. A claim must be genuine, the key insurance principle is for recovery of the losses only; and not to make any profit.
2. A full set claim documentation is important, such as the claim from; incident report; police report; quotation; photos and etc.
3. All documentation must be in order and the claim form must be fully completed and duly signed.
4. The cooperation and fast action taken by the insured is also very important.

Full set of claim documents were submitted on 8^th April 2020 to the insurer and claim offer was issued on 17^th April 2020 and claim for RM36k plus was paid on 27^th April 2020.

Prevention is always better than cure: –

• Better to engage a reliable and trusted transporter when transporting important and expensive materials.
• There must be a contract drawn up whereby the responsibility of the transporter is clearly and fully stated.
• The insurance claim only allowed for the actual replacement costs or the cost value of the goods; and NOT the selling price which inclusive of the profit margin. The principle of insurance “compensation or reimbursement of the losses”.