United States
Hong KongNotice of claim, claim forms and proof of loss
Notice of claim tells the insurer something has happened. The insurer then has to supply claim forms, and if it does not, the claimant may prove the loss in any reasonable way. Proof of loss is the evidence itself, due within a period the policy states.
Three provisions that only make sense in order, and the outline lists them in that order: notice of claim, claim forms, proof of loss. Each hands the ball to the other party, and the exam's questions are almost always about what happens when somebody drops it.
The sequence
| Step | Whose obligation | What happens if it is missed |
|---|---|---|
| Notice of claim | The claimant, within the policy period | Late notice is excused if it was not reasonably possible to give it sooner |
| Claim forms | The insurer, on receiving notice | The claimant may submit proof in any reasonable form instead |
| Proof of loss | The claimant, within the stated period | Late proof is excused where it was not reasonably possible, within limits |
Read the right-hand column down. Every deadline in this sequence has a reasonableness escape, which is unusual in a contract and is deliberate. A person who has just had a heart attack is not expected to file paperwork on schedule, and the provisions are drafted so that a claim is not lost to timing alone.
The claim forms provision is the insurer's obligation
This is the one candidates misread. On receiving notice, the insurer must send the claimant its forms. If it does not do so within the period the provision allows, the claimant is entitled to prove the loss in writing in any reasonable manner and the insurer must accept it.
So an insurer cannot slow a claim by failing to send paperwork. The obligation moves back to it, which is a genuinely useful thing for a producer to know when a client is being given the run-around.
What proof of loss actually is
- Written evidence of the occurrence, the character and the extent of the loss.
- Usually the completed claim form plus supporting medical documentation and bills.
- Due within the period stated in the policy, running from the date of loss or the end of a period of continuing disability.
- Not the same thing as the notice, which is simply a heads-up.
Notice says something happened. Proof of loss says what, how much and to whom. Confusing the two is the most common error in this trio and it is easy to prevent by remembering that one of them is a sentence and the other is a file.
The day counts for notice and proof of loss come from the model law the states adopted rather than from the Texas Insurance Code chapters we hold, so this site does not state them. The examinable substance is the sequence, the shifting of the obligation and the reasonableness escape, all of which are the same wherever the deadlines fall.
An insured gives timely notice of a claim. The insurer never sends claim forms. What may the insured do?
- Nothing until the forms arrive, since proof must be on the insurer's form
- Submit written proof of the occurrence, character and extent of the loss in any reasonable manner
- Treat the claim as admitted and demand payment
- Give notice again and restart the period
The provisions that follow
Once proof of loss is in, two more provisions take over: time of payment of claims, which sets how quickly the insurer must pay, and payment of claims, which sets who it pays. Both are covered in time of payment and payment of claims, and the five together are the whole claims story.
Two more sit behind them as the insurer's protections. Physical examination and autopsy lets the insurer examine the insured at its own expense while a claim is pending, and where not forbidden by law, order an autopsy. Legal actions stops the claimant suing before proof of loss has had time to be considered, and sets an outer limit for bringing an action.
Where it sits
- Section
- VI, provisions, clauses and riders, 15 questions
- Listed as
- Mandatory and optional provisions, sub-items 5, 6 and 7
- The rest of the sequence
- Sub-items 8 and 9, time of payment and payment of claims
- The insurer's checks
- Sub-items 10 and 11, examination and autopsy, legal actions
The opinion, and the concession
Learn this as a five-step story and you will not need to memorize which provision is which. Tell them, get the forms, prove it, get paid, and know who gets the money. Five sub-items in a row in the outline, in the order they happen, which is the outline being more helpful than it usually is.
The concession: the numbers are missing from this page and they are genuinely part of the topic. A candidate whose course prints them is not being misled, they are being given a figure from a source we have not verified. We would rather be visibly incomplete than confidently unsourced, and the sequence is what the questions turn on.
Common questions
What is the difference between notice of claim and proof of loss?
Notice tells the insurer that something has happened and starts the process. Proof of loss is the written evidence of the occurrence, character and extent of the loss, usually the claim form with medical documentation attached. One is a message, the other is a file.
What happens if the insurer does not send claim forms?
The claimant may submit written proof of the occurrence, character and extent of the loss in any reasonable manner, and the insurer must accept it. The provision exists so that an insurer cannot delay a claim simply by failing to send its own paperwork.
Can a claim be denied for late notice?
Not automatically. The provisions excuse late notice and late proof where it was not reasonably possible to comply sooner, within limits. Someone who has been seriously ill is not expected to have met a filing deadline, and the wording is drafted with exactly that in mind.
Can an insurer require a medical examination?
Yes. The physical examination and autopsy provision lets the insurer examine the insured as often as reasonably necessary while a claim is pending, at its own expense, and to order an autopsy where the law does not forbid it. Both are protections against fraudulent claims.