An insurance policy is a promise of compesation when things go wrong provided you fall within the policy’s terms and conditions.

If you are lucky, you may never have to make a claim against your insurance policy. However, when things go wrong and you are involved in an unexpected accident, sickness, disaster or experience loss that is covered by your insurance policy you can make a claim with your insurer.

What is a claim?

• When you make a claim on an insurance policy, you are formally notifying the insurance company that you have suffered a loss or damage that is covered by the policy and you are requesting action.
• The insurer will review your claim and see if the event or circumstances are risks covered by the policy.
• As the insured, you will need to provide proof it is a genuine claim and the insurer will need to be certain the claim satisfies the terms and conditions of your insurance policy.
• If your claim is accepted, the replacement, repair or payout (in case of life insurance) is made to the insured or beneficiary by the insurance company.
• The insurer will work out the value of the claim and provide the appropriate benefit specified in your insurance contract.

Steps To Follow Based on Incident;

The steps you follow after an incident depend on three critical factors:

1. Nature of the Incident (Whether it’s a minor or major accident, or theft.)
2. Who is to blame,
3. Type of Insurance Cover.

Understanding these factors will allow you to determine the best approach to file your claim.

Steps To Follow When You Get an Accident;

• Step 1: Scene Management After an Accident

Managing the accident scene is the first priority. Proper handling ensures safety and lays the groundwork for your claim.

1. Ensure Safety

Start by securing the area and ensuring everyone is safe:

2. Prevent futher accidents;

Check for immediate dangers, especially on busy highways or blackspots and move to a safe place if you are in a place where further accidents can occur

3. Access the situation

Check for injuries, damage extent [Minor or major] and determine if it’s safe to remain at the scene

4. Call for emmergency services

Contact an ambulance if injuries are present. Timely medical attention can save lives and prevent complications.

5.Amicable solution (minor accidents)

If the accident is minor, you can agree with the other driver to handle repairs without involving insurance or authorities. Document the agreement and keep repair cost records as evidence.

6. Contact the police

Traffic police usually visit accident scenes to record statements. If they don’t, call them or report to the nearest station to obtain a police abstrat.

• Step 2. Document

Whether the accident is minor or major, collect evidence accurately to support your claim:

1. Take clear photos of vehicle damage, license plates, and the surrounding area.
2. Record the names and contact details of witnesses.
3. Exchange insurance details with the other party.

• Step 3: Notify Your Insurance Provider

Once the immediate situation is under control, contact your insurer directly or through your agent as soon as possible. Most insurance companies require notification within 24 hours.

What to Do When Notifying Your Insurer

1. Provide a concise description of the incident:
2. Request a claim form and submission guidelines.
3. Follow any specific instructions provided by your insurer in the claim form.
4. By urgently informing your insurer, you ensure the process begins without unnecessary delays.

• Step 4: Complete and Submit the Claim Form

Accurately completing the claim form is critical to a successful claim. Include all necessary details and evidence collected at the scene.

What to Include in the Claim Form

• Personal details (e.g., name, policy number).
• A clear description of the incident (e.g., time, location, and events).
• Supporting documents:

1. Executed claim form
2. Detailed statement from the driver/owner ( if necessary)
3. police abstract
4. a copy of driving licence
5. a copy of drivers ID
6. Logbook copy ( in the name of insured)
7. Any claim supporting receipts eg. towing charges.
8. Pictures taken of the scene ( if available )

How To File a Theft Claim

If your vehicle is stolen, follow these simple steps:

• As soon as you notice your car is missing, contact the police and file a report. Get a police abstract.
• Call your insurer immediately, provide the police report, and submit documents like your vehicle’s registration and purchase receipt to confirm ownership. Complete the claim form as well.
• Stay in touch with your insurer for updates and provide any additional information they may need. 

What To Do if You are to Blame for The Accident ?

If you cause damage to someone else’s vehicle or property, follow these steps:

1. Provide the third party with your insurer’s contact information and policy number.
2. Document the claim by Take photos of their vehicle or property and record their details.
3. File a claim through your agent or insurer directly. Explaining the situation. Your insurer will manage the compensation process.

Making a medical claim generally follows two paths: Direct Settlement (Cashless) at a network provider or Reimbursement for out-of-pocket expenses

Direct Settlement (Cashless Claim)

This is the most common method when visiting a hospital within your insurer's approved network. 

• Identification: Present your insurance card and national ID or Bio-data at the hospital's insurance desk.
• Verification: The provider verifies your membership and limit via the insurer's system.
• Pre-authorization: For inpatient admissions or specialized procedures, the hospital must send a pre-authorization request to the insurer for approval.
• Settlement: Once approved, the insurer settles the bill directly with the hospital. You only pay for non-covered items or your policy's "co-payment" if applicable. 

Reimbursement Claim

Used if the insured visit a non-network provider or pay for services upfront (e.g., pharmacy bills) or  last expense benefits.

Follow these steps

• Notification: Inform your insurer as soon as possible, often within 24–48 hours of the incident.
• Documentation: Collect all original documents including;

1. A Claim Form duly filled and signed by both you and the attending doctor.
2. Original official receipts with itemised costs (consultation, lab, drugs).
3. Doctor's prescriptions and diagnostic reports (X-ray, lab results).
4. Discharge summary or medical report for hospital stays.
5. Fully completed beneficiary bank details / Mpesa Form

• Submission: Submit the completed file to your insurer or agent for proccesing. 
• Decision and Compensation; The insurer reviews the claims and advises on either;

1. Compensate 100% of the claim
2. compesate 80% or less
3. Decline the claim

compensation is made to insured bank account or Mpesa. 

• Last Expense Reimbursement claims Requirements;

1. Copy of burial permit/death certificate
2. Copy of beneficiary ID
3. Fully completed beneficiary bank details / Mpesa Form

Timeline: Claims must typically be submitted as soon as possible  but not latter then  45( consult for specific policy)  days of treatment; late submissions may be time-barred. 

PROCEDURE FOR WIBA  CLAIM

Step 1: Notify the Employer

• Immediate Reporting: Employees must report the injury or illness to their employer or supervisor as soon as possible, ideally within 30 days. Delays can jeopardize the claim.
• For severe accidents requiring emergency treatment, employees should seek medical care immediately and inform their employer afterward.

Step 2: Seek Medical Treatment

• Obtain medical treatment from a qualified healthcare provider. The attending doctor will provide a medical certificate or work capacity certificate detailing the injury, treatment required, and any recommended time off work.
• Inform the medical staff that the injury is work-related to ensure proper documentation.

Step 3: Employer Reports to the Agent or directly to insurance.

• The employer is responsible for reporting the injury to their WIBA insurance provider within 7 days of being notified (or 24 hours in the case of a fatality).
• The employer must provide: a written statement from the injured employee; statements from a supervisor and any eyewitnesses; and a completed WIBA claim form, including details about the workplace, machinery, or chemicals involved.

Step 4: Submit Claim Documents

• The employee or employer submits the necessary documents to the insurance provider, including: a WIBA claim form; medical reports and certificates; appointment letter of the claimant; and reports from the employer’s health and safety committee, if applicable.

• For complex cases, additional documents like police reports may be required for severe accidents or major damages.

Step 5: Medical Assessment (if applicable)

• For permanent incapacity claims, a medical board assesses the degree of disability to determine the compensation amount.
• The employee may need to attend a medical appointment arranged by the employer or insurer to verify the injury’s extent.

Step 6: Claim Processing and Settlement

• The insurance provider reviews the submitted documents and medical reports. If all requirements are met, the claim must be settled within 90 days, as mandated by WIBA.
• Compensation is paid directly to the employee (or their dependents in case of death) for medical expenses, lost wages, or lump-sum payments.

Step 7: Dispute Resolution

• If the claim is denied or disputed, employees can seek assistance from the Directorate of Occupational Safety and Health Services (DOSHS) or escalate the matter to the Employment and Labour Relations Court (ELRC).

• Legal representation may be necessary for complex cases. Employees can contact work injury lawyers for support in such cases.