Resolution SBS No. 3202-2013: Regulation for the Management and Payment of Claims

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Los Laureles Nº 214 - Lima 27 - Perú Telf.: (511) 6309000 Fax: (511) 6309239 Lima, May 24, 2013 Resolution S.B.S.
No. 3202-2013
The Superintendent of Banks, Insurance Companies and Private Pension Fund Administrators

CONSIDERING:

That, pursuant to Article 345 of the General Law of the Financial System and the Insurance System and the Organic Law of the Superintendence of Banks, Insurance Companies and Private Pension Fund Administrators, Law No. 26702 and its amendments, hereinafter the General Law, it is the objective of the Superintendence to protect the interests of the public within the scope of the financial and insurance systems;

That, through the Insurance Contract Law, Law 29946, the participation of claim adjusters in claim settlement processes is regulated, and certain obligations that must be fulfilled are established; as well as the pronouncement of the insurer regarding consent or rejection of claims is regulated;

That, it is necessary to regulate the articles of the law referred to the participation of claim adjusters and the pronouncement of the insurer, with the aim of establishing the necessary rules for the adequate management and payment of claims, and to guarantee that the obligations arising from the insurance contract are fulfilled in a timely manner without causing any detriment to the policyholder, the insured and/or the beneficiary;

That, in order to collect opinions from the general public regarding the proposal to modify the regulations, the prior publication of this resolution was ordered, under the provisions of Supreme Decree No. 001-2009-JUS;

Having the approval of the Adjunct Superintendencies of Private Pension Fund Administrators and Insurance, and of Legal Advisory, as well as of the Department of Products and Services for the User; and,

In exercise of the powers conferred by items 6 and 9 of Article 349 of the General Law,

RESOLVES:

Article First.- Approve the Regulation for the Management and Payment of Claims, in the terms indicated below:

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“REGULATION FOR THE MANAGEMENT AND PAYMENT OF CLAIMS

Article 1°.- Scope
The provisions of this Regulation are applicable to the insurance companies referred to in item D of Article 16 of the General Law, hereinafter the companies, as well as to claim adjusters, insofar as applicable.

Article 2°.- Definitions
For the purposes of the provisions of this standard, the following definitions are considered:

a. Claim adjusters: Natural and legal persons who perform the functions established in Article 343 of the General Law, and other regulations that govern their activity. b. Insured: Holder of the insurable interest object of the insurance contract; may also be the policyholder of the insurance.
c. Beneficiary: Holder of the indemnity rights established in the insurance contract.
d. Adjustment Agreement: Document in which the amount determined as compensation for the claim or the benefit to be borne by the company is established, within the framework of the insurance contract, prepared by the claim adjuster. e. Policyholder: Natural or legal person who enters into the insurance contract. In the case of an individual insurance, they may also have the status of insured. f. Days: Calendar days. For the calculation of the deadlines set forth in this Regulation, it must be considered that the deadline whose last day is non-working will expire on the next working day. g. Insurance Law: Insurance Contract Law, Law No. 29946. h. General Law: General Law of the Financial System and the Insurance System and Organic Law of the Superintendence of Banks, Insurance Companies and Private Pension Fund Administrators, approved by Law No. 26702, and its modifying regulations.
i. Claim settlement process: process that includes the evaluation of the validity of the contracted coverage in the policy, as well as, if applicable, the settlement of damages or losses caused by a claim to determine the benefit to be borne by the company, if applicable.
j. Property Damage Insurance: Those that guarantee the insured against the unfavorable consequences of a damaging event that may threaten their assets, and include insurance of goods, civil liability insurance, credit insurance and surety insurance. k. Personal Insurance: Those that provide coverage for the life, psychophysical integrity or health of the insured, including life insurance (death and survival), personal accident insurance and health insurance.
l. Coverage request: request made by the insured or the beneficiary to the company due to the occurrence of a claim regarding the contracted insurance coverage.
m. Superintendence: Superintendence of Banks, Insurance Companies and Private Pension Fund Administrators.

Article 3°.- Notice of the claim
In property damage insurance, the claim must be communicated to the companies by the policyholder, the insured, or the beneficiary, as soon as the occurrence is known and within a period not exceeding three (3) days, unless the corresponding insurance policy provides for a longer period. In the case of claims corresponding to the vehicle and transport branches, the notice of the claim must be presented to the company in the shortest possible time.

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In the case of personal insurance, the claim will be communicated to the companies within seven (7) days following the date on which the occurrence or the benefit is known, as applicable, unless the corresponding insurance policy provides for a longer period.

During the period to present the notice of the claim and, meanwhile, the company does not indicate otherwise, the insured cannot introduce changes in the damaged things as a consequence of the claim, nor remove, order or allow the removal of the debris left by the claim, unless they are carried out to reduce the damage, prevent its spread, or by order of some authority.

Likewise, the policyholder and/or the insured must comply with all legal obligations and contractual burdens specific to the claim that occurred. Non-compliance with these obligations by the policyholder and/or the insured will release the company from its responsibility regarding the claim, provided that it proceeds without delay to determine the causes of the claim and the settlement of the damages.

Non-compliance with the deadlines mentioned above by the insured or the beneficiary does not constitute a cause for rejection of the claim, but the companies may reduce the compensation up to the extent of the damage caused when the possibility of verifying or determining the circumstances of the claim by the companies and/or claim adjusters has been affected, with the exception of what is provided in the following paragraphs of this article. When the insured or the beneficiary prove their lack of fault, or the non-compliance is due to fortuitous event, force majeure or factual impossibility, the reduction of the compensation will not apply.

The fraud committed by the policyholder, the insured, or the beneficiary, in the non-compliance of the deadlines to communicate the claim, releases the companies from responsibility.

In case of inexcusable fault of the policyholder or the insured or the beneficiary, which causes the non-compliance of the deadlines to communicate the claim to the company, the right to be compensated is not lost if the lack of notice did not affect the possibility of verifying or determining the circumstances of the claim, or if it is demonstrated that the company has had knowledge of the claim or its circumstances by other means.

Article 4°.- Coverage Request
The insured or the beneficiary, as applicable, must present the coverage request to the company, including the complete documentation and information indicated in the insurance policy for the claim settlement process, through which the date and place of the occurrence, the cause and circumstances of the claim and the amount of the claimed damages or losses can be determined.

The coverage request presented to the insurance marketer has the same effects as if it had been presented to the company, with the company being responsible for errors or omissions derived from the marketing of insurance in which the marketer incurs, and for the damages that may be caused to the insured or beneficiaries. This without prejudice to the responsibility of the marketer towards the company.

Insureds must allow the companies and/or claim adjusters to carry out all necessary investigations to determine the validity of the coverage of a claim and the amount of the compensation or other benefit, as applicable; otherwise, the deadlines indicated in Articles 8 and 11 of this Regulation will not run.

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Article 5°.- Claim Settlement Process
The adjustment and settlement process aims to establish whether the claim is covered by the contracted insurance coverage and, if affirmative, the compensation to be paid or other benefit to be borne by the companies. The settlement of the claim can be carried out directly by the company or entrusted to a claim adjuster.

In cases where, due to the scope and consequences of the claim or when the company requires the hiring of a claim adjuster to evaluate and quantify damages or losses, the designation of the same must be made by mutual agreement between the company and the insured.

The designation of the claim adjuster must be made within three (3) days following the date of the notice of the claim, or the date on which the company becomes aware of the occurrence.

When the company receives the claim notice, it must propose to the insured, at least two (2) days before the expiration of the deadline, a list of three claim adjusters so that the insured expresses their agreement with the designation of one of the proposed adjusters.

For this purpose, companies must propose claim adjusters who are registered and authorized in the corresponding Registry under the Superintendence. In case the insured does not designate one of the proposed claim adjusters, the company will proceed to designate the claim adjuster before the expiration of the deadline, in order not to delay the start of the claim settlement process.

It is the responsibility of the company to verify that the claim adjusters proposed to the insured for the claim settlement process are authorized in the corresponding Registry under the Superintendence.

Article 6°.- Participation of claim adjusters 1

Article 7°.- Prohibitions for the participation of claim adjusters 2

Article 8°.- Settlement of the claim when a adjuster intervenes
The claim adjuster has a period of twenty (20) days to issue and present to the company the report that supports the coverage and settlement of the claim, or, otherwise, the rejection of the claim, counted from the date on which they received the complete documentation and information required in the insurance policy for the claim settlement process. If the claim adjuster requires additional clarifications or precision regarding the documentation and information presented, they must request them from the insured or the beneficiary before the expiration of the aforementioned deadline; which will suspend the deadline until the corresponding documentation and information is presented. The claim adjuster must inform the company, within twenty-four (24) hours following, when the documentation and information required for the claim settlement process has been completed.

The adjustment agreement drafted by the claim adjuster must indicate the amount of the determined compensation or benefit to be borne by the company, according to the corresponding report, which will be sent to the insured for signature as a sign of agreement.

In case the adjuster fails to issue and deliver the corresponding report that supports the coverage and settlement of the claim, or its rejection, it will be considered consented when the company

1 Article repealed by Resolution SBS No. 809-2019, published on 07.03.2019.
2 Article repealed by Resolution SBS No. 809-2019, published on 07.03.2019.

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has not pronounced on the claimed amount within thirty (30) days following the date on which all the documentation and information required in the policy for the claim settlement process was completed, with the exception of what is stated in Article 9.

Once the adjustment agreement, duly signed by the insured, is delivered to the company, it will have a period of ten (10) days to approve or reject it, understanding that if this period elapses without issuing a pronouncement, the claim has been consented, so the company must proceed to make the corresponding payment.

If the company disagrees with the compensation or benefit to its charge indicated in the adjustment agreement, it may request the claim adjuster to make a new adjustment, so that within a period not exceeding thirty (30) days it proceeds to consent or reject the claim, determine a new amount or propose to go to arbitration or the judicial route.

Article 9°.- Request for extension by the claim adjuster
In case the adjuster requires an additional period to conclude the claim settlement process, they may request the Superintendence, only once, a duly justified extension specifying the technical reasons and the required period, subject to the corresponding procedure established in the Single Text of Administrative Procedures of the Superintendence. This request suspends the period with which the claim adjuster has to issue the corresponding report, until the Superintendence issues a pronouncement and it is communicated to them.

The presentation of the extension request made to the Superintendence must be communicated to the company and the insured within three (3) days following the start of the administrative procedure. Likewise, the pronouncement of the Superintendence must be communicated to the insured and the company within the same period mentioned above, counted from the date on which the applicant became aware of the corresponding pronouncement.

Article 10°.- Claim Settlement Report
The opinion of the claim adjuster issued in the claim settlement report does not bind the parties and is independent of them. The claim adjuster must deliver simultaneously to the insured and the company the reports they draft, according to the development of the claim settlement process, and must keep available to the Superintendence the support of having delivered all reports, whether partial or final, at the physical or electronic addresses that the parties have indicated in the policy.

If the insured or the company do not agree with the settlement of the claim, they may designate another claim adjuster to draft a new report, who will be subject to the deadlines indicated in Articles 5 and 8. Otherwise, the parties may resort to the dispute resolution mechanism that corresponds.

Article 11°.- Settlement of the claim when no adjuster intervenes
Within thirty (30) days following the date of having received the complete documentation and information required in the policy for the claim settlement process, the company must pronounce on the consent or rejection of the claim. In case the company requires additional clarifications or precision regarding the documentation and information presented by the insured, it must request them within the first twenty (20) days of the aforementioned period; which will suspend the period until the corresponding documentation and information is presented.

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If the company does not pronounce within the thirty (30) day period referred to in the previous paragraph, it will be understood that the claim has been consented, unless a request for extension of the period with which the company has to consent or reject the claim is presented, as stated in the following article.

Article 12°.- Request for extension by the company
When the company requires an additional period to carry out new investigations or obtain evidence related to the claim, or the adequate determination of the compensation or benefit to its charge, it may request the insured to extend the aforementioned period; in the contrary case, it will be subject to procedure 91 established in the Single Text of Administrative Procedures of the Superintendence.

The presentation of the extension request made to the Superintendence must be communicated to the insured within three (3) days following the start of the administrative procedure. Likewise, the pronouncement of the Superintendence must be communicated to the insured within the same period mentioned above, counted from the date on which the applicant became aware of the corresponding pronouncement.

Article 13°.- Payment of the claim
Once the claim is consented, the company has a period of thirty (30) days to proceed to make the corresponding payment; otherwise, the company must pay the insured or the beneficiary a moratory annual interest equivalent to one point five (1.5) times the average rate for active operations in Peru, according to the currency agreed in the insurance contract for the entire time of the delay.

The policyholder of the insurance, even when in possession of the policy, cannot collect the corresponding compensation or benefit, without the express consent of the insured, unless the policy is endorsed in their favor.

Article 14°.- Dispute Resolution Mechanisms
The policyholder, the insured and/or the beneficiary may agree with the company to submit disputes arising from the insurance contract to arbitration or another dispute resolution mechanism, as provided in item c) of Article 40 and in Article 46 of the Insurance Law, when the damages or losses claimed from the company as a consequence of a claim are equal to or greater than 20 UIT.

Article 15°.- Rejection of claims
The rejection of a claim must be justified by the company, and must have the respective support in the claim file. Claim files must contain the technical reports that have been issued, the reports of the claim adjusters, if applicable, and other documents that support the decision adopted by the company. These files must be available to the Superintendence, when it so requires.

The company must inform in detail, through communication sent to the insured or the beneficiary, as applicable, through the mechanisms and at the addresses agreed in the policy, the reasons that support the rejection of the claim, attaching a copy of the documents taken into account to justify its decision, duly signed by the person in charge of the area responsible for evaluating the claims. This communication must be drafted and delivered to the insured or the beneficiary within the deadlines established in Articles 8 or 11 of this Regulation, as applicable.

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The proof of delivery of the information referred to in this article must be kept by the companies in the corresponding claim files.

In case of intermediation by an insurance broker, companies must send a copy of the claim rejection communication to the broker so that it fulfills its obligation of advice.

Article 16°.- Disagreement with the rejection of the claim
If the insured or the beneficiary are not satisfied with the grounds used by the company to support the rejection of the claim, they may file a complaint with the company in accordance with the Service Circular on User Attention, or resort to the dispute resolution mechanism that corresponds.

In such case, the insured or the beneficiary may present, at their own cost, the appraisals or evidence of their choice that they deem convenient, and request the reimbursement of the expenses incurred, provided that their complaint is well-founded.

Article 17°.- Information to be included in the claim rejection communication
The claim rejection communication must contain information on the dispute resolution mechanisms to which the insured or the beneficiary may resort, in case they are dissatisfied with the company's pronouncement, according to the following text:

“In case of disagreement with the grounds for the rejection of the claim, you may resort to dispute resolution routes, such as the Insurance Ombudsman (www.defaseg.com.pe), the National Institute for the Defense of Competition and the Protection of Intellectual Property – INDECOPI (www.indecopi.gob.pe), or the Judiciary or arbitral instance, as agreed. To request guidance, you can contact the User Attention Platform of the Superintendence of Banks, Insurance Companies and AFP at the toll-free number 0-800-10840.”

Article 18°.- Information to be sent to the Superintendence
Companies must send to the Superintendence, on a quarterly basis, the list of rejected claims, according to the annexes indicated below:

• Annex No. ES-5A: Summary of rejected claims
• Annex No. ES-5B: Rejected claims in settlements carried out with the participation of claim adjusters
• Annex No. ES-5C: Rejected claims in settlements carried out by the company

The aforementioned information must be sent through the software “External Capture and Validation Submodule” (SUCAVE), according to the provisions issued by the Superintendence.

The previously indicated information corresponds to the claims rejected during the quarter being reported, and must be presented within the first fifteen (15) calendar days of the following quarter.

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Los Laureles Nº 214 - Lima 27 - Perú Telf.: (511) 6309000 Fax: (511) 6309239 Companies must preserve, at the disposal of the Superintendence, the files of rejected claims that are reported in Annexes No. ES-5B and ES-5C, for the proper development of control and supervision actions carried out by the Superintendence.

Article 19th.- Claim Files
Companies must keep claim files available to the Superintendence with the following minimum information:
a) Notice of the claim. b) Information regarding the insurance policy. c) Communications sent to the policyholder, the insured, and/or the beneficiary; these must contain the dates and charges of receipt corresponding to communications addressed to their physical addresses indicated in the policy, or the corresponding confirmation of receipt when communications are sent to electronic addresses. d) Reports issued by claim adjusters. e) Adjustment agreement, if applicable, signed by the insured. f) Certificate proving the payment of the indemnity, if applicable, or a copy of the claim rejection communication delivered to the insured.”

Article Second.- Modify articles 5th and 34th of the Regulation of the Registry of Intermediaries and Insurance Auxiliaries, Resolution SBS No. 1797-2011, in the following manner:

“Article 5th. Prohibitions
Those registered in the Registry are prohibited from:
a) Carrying out actions that may harm or harm the policyholders or contractors, insured persons, or insurance and/or reinsurance companies; b) Exercising the activity through third parties not authorized by this Superintendence, with the exception of what is established in article 34th; and, c) Exercising their functions in risks or activities for which authorization different from that granted by this Superintendence is required. Insurance intermediaries in general are prohibited from including any type of clause in the insurance contract and/or the reinsurance contract that limits or restricts the direct relationship between the insured and the insurance company, or between the latter and the reinsurer, as applicable. Insurance brokers are prohibited from:
d) Ceding totally or partially the intermediation commission to persons not registered in the Registry; e) Offering insurance plans, premiums, coverages, and conditions for the contracting of insurance policies, different from those proposed by insurance companies; f) Intermediating in the contracting of insurance with insurance companies not authorized to operate in the country; g) Making announcements using designations that do not comply with what is established in article 15th of this Regulation; h) Intermediating in the contracting of policies that are not registered in the Registry of Insurance Policies and Technical Notes of the Superintendence; and i) Carrying out the prohibited activities referred to in article 339º of the General Law.”

“Article 34th. Activity of Insurance Auxiliaries

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Los Laureles Nº 214 - Lima 27 - Perú Telf.: (511) 6309000 Fax: (511) 6309239 Insurance auxiliary legal entities must permanently maintain in their professional roster, at least one qualified insurance auxiliary, who has authorization to perform insurance adjustments or appraisals in each specialty for which said company has received authorization from the Superintendence.”

Article Third.- Incorporate article 33-Ath of the Regulation of the Registry of Intermediaries and Insurance Auxiliaries, Resolution SBS No. 1797-2011, according to the following:

“Article 33Ath. Guarantee of Compliance with Responsibilities To maintain the status of qualified in the Registry, claim adjusters must have a civil liability insurance policy that guarantees the correct and full fulfillment of the responsibilities assumed in the exercise of the functions established in article 343º of the General Law, according to the conditions and requirements indicated by the Superintendence.”

Article Fourth.- The annexes mentioned in article 18th of the provisions approved by means of this resolution, are published on the electronic Portal of this Superintendence (www.sbs.gob.pe), in accordance with what is provided by Supreme Decree No. 001-2009-JUS.

Article Fifth.- This Resolution enters into force the day after its publication in the Official Gazette “El Peruano”, from which date Circular S-610-2004 is repealed.

Register, communicate, and publish.
DANIEL SCHYDLOWSKY ROSENBERG
Superintendent of Banks, Insurance and Private Pension Fund Administrators

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ANNEX No. ES – 5A
SUMMARY OF REJECTED CLAIMS
Information corresponding to the quarter................................................

SBS Code	Risk	Number of Reported Claims	Number of Rejected Claims	Amounts of Rejected Claims	Average processing time for reported claims	Average processing time for rejected claims
1	2	3	4	5	6	7

Notes.-

1. Corresponds to the product registration code at the Superintendence.
2. Risk codes from the Concordant Risk Table of the Chart of Accounts for Companies of the Insurance System, Resolution SBS No. 348-95.
3. Total number of claims reported in the quarter being reported.
4. Total number of claims rejected in the quarter being reported.
5. Total amount of rejected claims in the period being reported, expressed in New Soles with two decimals. For foreign currency operations, use the accounting exchange rate at the close of the quarter being reported.
6. Average processing time for the reported claims being reported. This time is calculated from the date of receipt of the coverage request with the complete information indicated in the policy for the claim settlement process until the date of receipt of the response to the insured.
7. Average processing time for rejected claims. This time is calculated from the date of receipt of the coverage request with the complete information indicated in the policy for the claim settlement process until the date of receipt of the response to the insured.

General Manager Claims Officer

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ANNEX No. ES – 5B
REJECTED CLAIMS IN SETTLEMENTS WITH PARTICIPATION OF CLAIM ADJUSTERS
Information corresponding to the quarter...............................

Notes.-
Corresponds to claims rejected during the quarter being reported.

1. Risk code (Profits and Losses) according to the Concordant Risk Table of the Chart of Accounts for Companies of the Insurance System, Resolution SBS No. 348-95.
2. Code or number of the insurance policy assigned by the company.
3. Code or number of the certificate assigned by the company in the contracting of group or collective insurance. In the case of individual policies, record the same number as the insurance policy.
4. Code or number of the claim assigned by the company.
5. Name of the insured if natural persons or legal name in case of legal entities.
6. Amount of the claim claimed by the insured and rejected, expressed in New Soles with two decimals. In case of foreign currency, use the accounting exchange rate at the close of the quarter being reported.
7. Corresponds to the date the claim occurred. In dd/mm/yyyy format.
8. Corresponds to the date the insured or beneficiary presents the coverage request with the complete information indicated in the policy for the claim settlement process. In dd/mm/yyyy format.
9. Corresponds to indicate YES or NO.
10. Corresponds to the date the adjustment agreement signed by the insured or beneficiary is presented to the company. In dd/mm/yyyy format.
11. Corresponds to the date the company communicated the rejection of the claim. In dd/mm/yyyy format.
12. Indicate the reason for rejection: (1) Application of exclusions; (2) Non-compliance with charges or obligations indicated in the policy (3) Pre-existing illness; (4) Lack of payment of the commercial premium; (5) Fraudulent documentation; (6) Other cases.
13. Indicate YES or NO within the framework of what is provided for in articles 8th and 11th of the Regulation.

Risk	Policy Number	Certificate Number	Claim Number	Name or Legal Name of Insured	Amount of Rejected Claim	Date of Occurrence	Date of Request	Adjuster Extension	Date of Presentation of Agreement	Date of Rejection	Reason for Rejection	Rejection within Timeframe
1	2	3	4	5	6	7	8	9	10	11	12	13

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ANNEX No. ES – 5C
REJECTED CLAIMS IN SETTLEMENTS EFFECTED BY THE COMPANY
Information corresponding to the quarter...............................

Notes.-
Corresponds to claims rejected during the quarter being reported.

1. Risk code (Profits and Losses) according to the Concordant Risk Table of the Chart of Accounts for Companies of the Insurance System, Resolution SBS No. 348-95.
2. Code or number of the insurance policy assigned by the company.
3. Code or number of the certificate assigned by the company in the contracting of group or collective insurance. In the case of individual policies, record the same number as the insurance policy.
4. Code or number of the claim assigned by the company.
5. Name of the insured if natural persons or Legal Name in case of legal entities.
6. Amount of the claim claimed by the insured and rejected, expressed in New Soles with two decimals. In case of foreign currency, use the accounting exchange rate at the close of the quarter being reported.
7. Corresponds to the date the claim occurred. In dd/mm/yyyy format.
8. Corresponds to the date the insured or beneficiary presents the coverage request with the complete information indicated in the policy for the claim settlement process. In dd/mm/yyyy format.
9. Corresponds to indicate YES or NO.
10. Corresponds to the date the company communicated the rejection of the claim. In dd/mm/yyyy format.
11. Indicate the reason for rejection: 1) Application of exclusions, (2) Non-compliance with charges or obligations indicated in the policy, (3) Pre-existing illness, (4) Lack of payment of the commercial premium, (5) Fraudulent documentation, (6) Other cases
12. Indicate YES or NO within the framework of what is provided for in articles 11th and 12th of the Regulation.

Risk	Policy Number	Certificate Number	Claim Number	Name or Legal Name of Insured	Amount of Rejected Claim	Date of Occurrence	Date of Request	Company Extension	Date of Rejection	Reason for Rejection	Rejection within Timeframe
1	2	3	4	5	6	7	8	9	10	11	12