See - https://www.manilatimes.net/2019/09/30/opinion/columnists/seeking-help-from-insurance-commission-on-money-claims/623775/
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SEEKING HELP FROM INSURANCE COMMISSION ON MONEY CLAIMS
By RANDY B. ESCOLANGO
SEPTEMBER 30, 2019
RANDY B. ESCOLANGO
DISAGREEMENTS over money claims can happen in many insurance (life and non-life) and Mutual Benefit Associations’ (MBA) dealings.
Suppose an insured person suffers a loss and claims that it was due to a risk or peril he was insured against, but the insurer denies such claim and avoids payment of liability.
If the insured disagrees and still believes that he has the right to be paid by the insurance company, should he immediately hire a lawyer and file a legal case against the insurer in court?
What if his claim is just a meager P5,000, should he push through with the lawsuit?
Is it worth going through the entire formal legal process for such a relatively small amount of money?
Should he just let it go and move on with his life despite his loss resulting from the damage done to his property or an untimely death of a loved one?
These issues on money claims and the tiresome and lengthy processes that one must undergo to settle disagreements over such claims often discourage potential buyers from obtaining insurance and trusting the entire insurance system.
In recognition of this matter, the Insurance Code of the Philippines provides a recourse for the insured to settle claims and/or complaints against the insurer by allowing the Insurance Commission (IC) to adjudicate or decide over claims and/or complaints involving any loss, damage, or liability for which the latter may be answerable.
The scope of the IC’s authority to adjudicate is for a single claim for loss, damage, or liability not exceeding P5 million, excluding interest, cost and attorney’s fees.
When the insured claim is denied but he disagrees with it, his initial step could be to seek help from and file an informal complaint with the Public Assistance and Mediation Division (PAMD) of the IC, either by contacting this government division through phone, mail, and/or email, or directly by visiting its office.
The PAMD may shed light and provide clarity on the denial of claim and conduct a mediation conference to amicably settle the issue at hand.
Note that no fees are required in filing an informal complaint with the PAMD.
Engaging the services of a lawyer is not yet required during the mediation conference.
If the insurer still denies the claim and no amicable settlement is reached, the insured may formally file a written complaint against the insurer with the Claims Adjudication Division (CAD) of the IC.
The commencement of his action against the insurer shall begin with a filing of a verified complaint with the CAD, stating that his allegations are true and correct of his own knowledge.
The complaint should state the names and addresses of the parties, the substance of the claim, the date when the loss occurred, the amount of claim, the grounds of action, the relief sought, an allegation that there is final denial of claim by the insurance company, and that there is no pending mediation conference with the PAMD of the IC.
The verified complaint may also be filed with any regional offices of the IC in Davao and Cebu, aside from its main office in Manila.
As opposed to an informal complaint, filing a formal complaint with the CAD of IC entails some costs, such as docketing fee, summons and legal research fund fees.
Filing fees may range from P1,000 for claims worth less than P100,000, or up to 30,000 if the claim reached P4 to P5 million.
Indigent or poor complainants may be exempted from paying docket and other legal fees once found to be indeed lacking money or property enough to sustain his family’s needs.
The normal proceedings for regular money claims after the filing of a formal complaint usually include those stated in IC’s Memorandum Circular 2014-1.
These are the following:
Suppose an insured person suffers a loss and claims that it was due to a risk or peril he was insured against, but the insurer denies such claim and avoids payment of liability.
If the insured disagrees and still believes that he has the right to be paid by the insurance company, should he immediately hire a lawyer and file a legal case against the insurer in court?
What if his claim is just a meager P5,000, should he push through with the lawsuit?
Is it worth going through the entire formal legal process for such a relatively small amount of money?
Should he just let it go and move on with his life despite his loss resulting from the damage done to his property or an untimely death of a loved one?
These issues on money claims and the tiresome and lengthy processes that one must undergo to settle disagreements over such claims often discourage potential buyers from obtaining insurance and trusting the entire insurance system.
In recognition of this matter, the Insurance Code of the Philippines provides a recourse for the insured to settle claims and/or complaints against the insurer by allowing the Insurance Commission (IC) to adjudicate or decide over claims and/or complaints involving any loss, damage, or liability for which the latter may be answerable.
The scope of the IC’s authority to adjudicate is for a single claim for loss, damage, or liability not exceeding P5 million, excluding interest, cost and attorney’s fees.
When the insured claim is denied but he disagrees with it, his initial step could be to seek help from and file an informal complaint with the Public Assistance and Mediation Division (PAMD) of the IC, either by contacting this government division through phone, mail, and/or email, or directly by visiting its office.
The PAMD may shed light and provide clarity on the denial of claim and conduct a mediation conference to amicably settle the issue at hand.
Note that no fees are required in filing an informal complaint with the PAMD.
Engaging the services of a lawyer is not yet required during the mediation conference.
If the insurer still denies the claim and no amicable settlement is reached, the insured may formally file a written complaint against the insurer with the Claims Adjudication Division (CAD) of the IC.
The commencement of his action against the insurer shall begin with a filing of a verified complaint with the CAD, stating that his allegations are true and correct of his own knowledge.
The complaint should state the names and addresses of the parties, the substance of the claim, the date when the loss occurred, the amount of claim, the grounds of action, the relief sought, an allegation that there is final denial of claim by the insurance company, and that there is no pending mediation conference with the PAMD of the IC.
The verified complaint may also be filed with any regional offices of the IC in Davao and Cebu, aside from its main office in Manila.
As opposed to an informal complaint, filing a formal complaint with the CAD of IC entails some costs, such as docketing fee, summons and legal research fund fees.
Filing fees may range from P1,000 for claims worth less than P100,000, or up to 30,000 if the claim reached P4 to P5 million.
Indigent or poor complainants may be exempted from paying docket and other legal fees once found to be indeed lacking money or property enough to sustain his family’s needs.
The normal proceedings for regular money claims after the filing of a formal complaint usually include those stated in IC’s Memorandum Circular 2014-1.
These are the following:
1. a response or an answer from the insurance company over a period allowed by law, or a motion to dismiss the case on the grounds found in Rule 6, Section 1, such as the following: lack of jurisdiction of the IC over the case; the same case involving the same party and same cause of action has been filed in another court; and the complaint does not involve any claim against insurance or MBAs;
2. A final mediation conference to exhaust possibility of amicable settlement;
3. a provision of judicial affidavits, and examination of witnesses;
4. pre-trial brief submissions and appearance in pre-trial conference;
5. attendance in the hearing proper led by the Insurance Commissioner or any hearing officers (i.e. lawyer/s under the Claims Adjudication Division of the IC);
6. decision or order;
7. motion for reconsideration; and
8. appeal on the order or decision, among others.
Note that like a case in court, the parties may be represented by lawyers.
Also, if no appeal or motion for reconsideration is filed within 15 days from receipt of the judgment, final order or decision rendered by the IC, the same becomes final and may be executed and enforced accordingly.
Lastly, it should also be mentioned that for convenience and practicability, the regular claims proceeding should follow the Rules of Court as specified in the 1997 Rules of Civil Procedure in suppletory character or to supply deficiencies in regulation.
The next column will discuss the rules of procedure for a single claim not exceeding P200,000, exclusive of interest, attorney’s fees and cost.
The rules of procedure are embodied in IC Circular 2016-01 otherwise known as the Rules of Procedure for Small Claims cases in the Insurance Commission.
The author is the deputy commissioner for legal services of the Insurance Commission. He may be contacted at rb.escolango@yahoo.com.
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2. A final mediation conference to exhaust possibility of amicable settlement;
3. a provision of judicial affidavits, and examination of witnesses;
4. pre-trial brief submissions and appearance in pre-trial conference;
5. attendance in the hearing proper led by the Insurance Commissioner or any hearing officers (i.e. lawyer/s under the Claims Adjudication Division of the IC);
6. decision or order;
7. motion for reconsideration; and
8. appeal on the order or decision, among others.
Note that like a case in court, the parties may be represented by lawyers.
Also, if no appeal or motion for reconsideration is filed within 15 days from receipt of the judgment, final order or decision rendered by the IC, the same becomes final and may be executed and enforced accordingly.
Lastly, it should also be mentioned that for convenience and practicability, the regular claims proceeding should follow the Rules of Court as specified in the 1997 Rules of Civil Procedure in suppletory character or to supply deficiencies in regulation.
The next column will discuss the rules of procedure for a single claim not exceeding P200,000, exclusive of interest, attorney’s fees and cost.
The rules of procedure are embodied in IC Circular 2016-01 otherwise known as the Rules of Procedure for Small Claims cases in the Insurance Commission.
The author is the deputy commissioner for legal services of the Insurance Commission. He may be contacted at rb.escolango@yahoo.com.
x x x."
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