Article 3. Financial support for expenses for payment of insurance coverage

Insurance compensation and its essence

The insurance system is structured in such a way that if the circumstances specified in the policy occur, the victim is entitled to a certain amount. This amount is called insurance compensation. It can be paid to different persons based on the terms of the insurance contract.

Recipients of funds are:

• Policyholder . The one who insured the risks. This is not necessarily the owner of the property, perhaps another person if insurance is necessary in his interests;
• Beneficiary . The person in whose favor an insurance policy is drawn up. When an insured event occurs, payment is made not to the policyholder, but to a third party indicated in the policy. This could be a relative or any other person;
• Heirs of the policyholder. Immediate relatives (spouse, children, sisters, brothers, etc.).

Insurance compensation is a payment that can be made in two forms:

1. Monetary . The amount calculated based on the damage caused as a result of the risk is transferred to the policyholder’s account;
2. Natural . Work, treatment and other services are reimbursed. For example, if a car is damaged in an accident, the insurance company transfers funds to the car service center, which will be used for repairs. Often in such cases, insurance companies have partners who provide restoration services. Moreover, the contract clearly stipulates compensation in kind from a specific partner. If the client violates this condition and contacts, for example, another car service, he will be denied compensation.

All conditions for receiving compensation are always specified in the concluded contract. In order for the company to pay funds to cover the damage, it is necessary to promptly notify about the occurrence of the insured event.

The main thing is not to take any independent actions to eliminate the consequences. This will significantly reduce the amount of payments, and sometimes may cause a refusal.

Social security law in Russia

• act on an industrial accident or act on an occupational disease;
• a certificate of the average monthly earnings of the insured for the period chosen by him to calculate monthly insurance payments;
• conclusion of a medical and social examination institution on the degree of loss of professional ability of the insured;
• conclusion of a medical and social examination institution on the necessary types of social, medical and professional rehabilitation of the insured;
• a civil contract providing for the payment of insurance premiums in favor of the insured, as well as a copy of the work record book or other document confirming that the victim is in an employment relationship with the insured;
• death certificate of the insured;
• a certificate about the family composition of the deceased insured;
• notification of a medical institution about the establishment of a final diagnosis of an acute or chronic occupational disease (poisoning);
• conclusion of the center of occupational pathology on the presence of an occupational disease;
• a document confirming that one of the parents, spouse or other family member of the deceased is caring for the children, grandchildren, brothers and sisters of the insured who have not reached the age of 14 years or have reached the specified age, but are recognized as requiring outside care for health reasons, does not work;
• a certificate from an educational institution stating that a family member of the deceased insured person entitled to receive insurance payments is studying full-time at this educational institution;
• documents confirming the costs of social, medical and professional rehabilitation of the insured according to the conclusion of a medical and social examination institution;
• conclusion of a medical and social examination institution on the connection between the death of the victim and an industrial accident or occupational disease;
• a document confirming the fact of being a dependent or establishing the right to receive maintenance;
• rehabilitation program for the victim.

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Principles of insurance compensation

No matter which insurance company you go to, there are specifics in paying compensation. Their presence prevents the actions of fraudsters. The approximate list of principles on which damages are paid is the same.

The main ones are:

• If you insure an object with several insurers at once, the total amount of compensation in the event of an insured event cannot exceed the actual cost of the object. For example, the cost of an apartment is equal to 5,000,000 rubles. She is insured by two insurers for 4,000,000 and 3,000,000 rubles, respectively. As a result of the fire, almost nothing remained of the housing. The amount of compensation will be a maximum of 5,000,000 rubles;
• The amount of compensation cannot exceed the actual value of the property . If the terms of the policy do not provide for the payment of a specific amount, regardless of the level of risk encountered. This principle means that if an object costs 200,000 rubles, then the company will not be able to reimburse you 250,000 rubles;
• The amount of compensation due under the insurance policy will be paid regardless of other payments due . Social, compensation for moral damage by a court decision by a third party, etc.;
• If the amount for which an object is insured does not exceed the value of this object, then the maximum compensation will not be equal to the actual value of the property . For example, the cost of a car is 1,800,000 rubles. He is insured for 1,000,000 rubles. As a result of an accident, the car cannot be restored. The maximum possible compensation will be 1,000,000 rubles.

These principles form the core of insurance, and therefore every policyholder or beneficiary should know them. There are often cases when persons with a policy, upon the occurrence of an insured event, receive compensation significantly less than what they expected.

A lawsuit is filed, as a result of which payment to the policyholder is still denied. The result is wasted time and money. To avoid this, carefully study the terms of the insurance contract, and also take into account the principles we described above.

Forms of insurance coverage

Occurring insurance events are divided into various groups. The most popular classification of forms by insurance object, which includes the following categories:

1. Property insurance. The main purpose of property insurance is the official protection of real estate and compensation for possible damage. Its objects include any property owned by the policyholder:

• transport;
• Residential Properties;
• land;
• harvest;
• animals;
• inventory;
• equipment, etc.

2. Personal insurance. Allows you to insure a person’s health and even life. It includes:

• health and life insurance;
• social insurance;
• pension insurance;
• health insurance, etc.

This type of insurance allows you to provide protection against possible risks that threaten a person’s performance, health and, in some cases, life. Since it is impossible to objectively assess life or death, insurance amounts are calculated taking into account the financial capabilities of the insured and his wishes. In this case, the insured individual can only try to prevent financial difficulties that will be likely after disability or death.

How is insurance compensation paid?

The method of payment of insurance compensation is an important condition of the contract. You should pay first attention to it, since it determines how you will receive funds.

There are three main payment options in the Russian Federation:

1. Proportional . In this case, compensation is calculated as a percentage of the amount insured. For example, the cost of a car is 360,000 rubles. He is insured for 290,000 rubles. As a result of the accident, the appraiser determined that the vehicle suffered damage of 30% of its value. The payment amount will be 30%*290000 = 87,000 rubles;
2. For the first risk . Then it is paid based on the actual damage without taking into account interest on the amount insured.

Example. The same vehicle, insured for 290,000 rubles, suffered damage after an accident. The cost of restoration work was calculated by the appraiser to be 72,000 rubles. This amount will be the insurance compensation. In subsequent insurance situations during the validity of the policy, the amount of potential compensation will be reduced by 72,000 rubles until it is completely spent. If by the end of the insurance contract the balance of compensation is 2,000 rubles, and the newly received damage is equal to 56,000 rubles, then only 2,000 rubles will be paid;

1. Based on a franchise . Such an agreement means that you will recover part of the losses at your own expense. For example, the policy states that damage equal to or less than 15,000 rubles is paid by the owner of the property, and everything in excess is covered by the insurance company. When drawing up such an agreement, insurers often offer reduced rates compared to the two previous types of compensation. In this case, if the estimated damage is 35,000 rubles, you pay 15,000 rubles out of your own pocket, and the remaining 20,000 rubles are reimbursed to you by the insurer.

The methods of compensation usually depend on the object of insurance and are specified in the policy.

There are also two types of payments based on the terms of the insurance contract:

• One-time . Within the scope of the agreement. Paid upon the occurrence of an insured event in one payment. This includes, for example, home or transport insurance;
• Periodic . For example, once a month. This payment procedure is typical for life insurance. Surviving to a certain age guarantees the payment of a monthly annuity by the insurance company.

Payments in individual insurance

The designation “sum insured,” like the concept of “insurance coverage,” is a synonym for the phrase “payments made under an individual insurance agreement.” In this case, the insurance company undertakes to pay the amount of money stipulated by the agreement once or at certain intervals, depending on the terms of the concluded contract, in cases where a specified age has been reached, damage has been caused to the health of the insured person, as well as in the event of another insured event. Pensions can be paid, annuities - fixed amounts paid at certain intervals, annuities - successive periodic payments.

How to receive insurance payment

In order for the insurer to pay the required amount, you need to follow a few simple steps. Their sequence is important, since the amount of compensation directly depends on it.

Upon the occurrence of an insured event, you will need:

1. Call the competent service . If a house catches fire, we call the fire department, if the neighbors are flooded, we call the management company, if a theft has occurred, we call the police, etc. The main thing at this step is to promptly notify the authorities about what happened. This needs to be done as early as possible. At the same time, it is not recommended to take any action to eliminate the damage on your own;
2. Submit an application for compensation for the damage incurred to the insurance company . Typically, such an application form is included in the policy and is issued by the insurer when drawing up the contract. It indicates the circumstances of the incident, draws up a diagram (if necessary), writes down the date, exact address, and participants of the incident. A form and sample application can be obtained from the office of the insurance company or downloaded from the company’s website. It is important to comply with the deadlines for submitting your application. Each company has its own. Find out this time period immediately; late submission of the application may result in refusal of payment;
3. Provide all documents to the insurance company . Passport, property documents, inventory of existing property, appraiser's conclusion, medical examination results and other papers based on the situation. A detailed list of them can be found by calling the insurance company;
4. Wait for the insurer's decision on your application . The period may drag on for up to a month or more if a criminal case is initiated over the situation or the insurance company does not have time to calculate the amount of damage. Moreover, if the payment period is delayed due to the fault of the insurance company, then you are entitled to compensation as a percentage of the final compensation for each day of delay;
5. Receive insurance compensation . Most often, it is translated according to the details you specified in the application. It is important here not to make mistakes in their writing. Otherwise, the funds may go to another person, and their return will be difficult. Your application will be assigned a number by which you can find out about the payment process. Call the hotline, call the digital sequence, and in response the operator will report the current situation.

When an insured event occurs, you should not panic. If you are confused and don’t understand how best to proceed, call the hotline number indicated on the insurance policy form.

Always keep the contract with the insurance company in a visible place, this will speed up the process of finding the required phone number. The consultant will explain the sequence of actions to you and answer any questions.

There is a process for receiving payments called direct reimbursement. It means that you, as a victim, have the right to seek compensation from your insurance company. This greatly simplifies the task and frees you from additional hassle.

How is the compensation amount calculated?

We have already told you that there are three main options for paying compensation. Based on them, let's look at how the victim can independently calculate the amount of compensation. The simplest calculations will be in two cases: for the first risk and the deductible.

In the first case, the risk is calculated based on the amount for which the object is insured and the amount of damage. If the damage is less than the insured amount, then the full amount of damage is paid. If the loss exceeds the insurance amount under the policy, only this amount is paid. The remaining restoration work is carried out at the expense of the policyholder.

With a deductible, the policy stipulates a certain amount, damage below which is paid by the owner of the property. Anything higher than the amount stated in the contract is paid from the insurer’s fund.

The proportional payment system is the most complex.

To calculate the amount of compensation, the formula is used: sum insured/cost of the object*cost of damage.

The result of the calculations will be the amount that the insurance company will pay.

It is important to consider that the amount of compensation depends on the terms of the contract. If this is a standard policy (also called a box policy), which offers a ready-made program and a certain set of risks, then the payments under it are often much lower than the actual damage.

If you take out a policy on individual terms, under which your specific object is assessed in all respects, then you can receive compensation that will correspond to its value.

Insurance systems

The term "insurance system" is used to describe the method of compensation for losses incurred. Depending on the system, the ratio between insurance coverage and actual loss is calculated. For example, if an object valued at 10 million rubles is insured for 5 million, then in this case the level of insurance coverage will be 50%.

There are several systems using different methods of compensation for losses.

Why do insurers refuse to pay?

There are often situations as a result of which insurance companies refuse compensation. The reasons for such actions are approximately the same among most insurers. You need to know them in advance so as not to be disappointed in the insurance system later.

The grounds for refusal of payments may be as follows:

• Incorrect information about the policyholder specified in the policy . Verify all information provided by the insurance company representative. If there is an error in the data, this will become a legitimate reason for refusing compensation. To receive payment, you will need to present your passport, and if some of the data from the policy does not match your passport data, then your application will not even be accepted;
• The claim for damages was submitted to the insurance company later than the period specified in the contract . The insurance policy contains a time period during which you are required to report the incident. If you do not do this, you may not receive a refund;
• The event that occurs is not covered by insurance . Carefully study the list of risks for which you can expect compensation. Check with the insurer under what circumstances payments are not made;
• Lack of any documents . For example, you forgot to initially call the housing and communal services and call a representative to record the neighbors’ drowning. This fact will become a serious obstacle to the payment of money;
• The insured event is the fault of the policyholder . If the incident was caused by you, then you will not receive any compensation. For example, you left home and forgot to close the door. In your absence, thieves entered the apartment and took away valuables. If it is proven that you left the door open, you will not receive any payments;
• If the policyholder's actions are considered fraudulent . For example, today there was a fire, you took out an insurance policy in the evening of the same day to compensate for the losses. The next day you report what happened and demand compensation. Such actions are quite difficult to implement, and they definitely will not lead to good things. For the sake of money, some owners also engage in dishonest behavior. For example, they initiate a theft, call the police and file a claim for damages. True, such cases can result in criminal liability.

What if the insurance company refuses to pay?

There are also situations when, upon the occurrence of an insured event, you did everything strictly according to the insurer’s recommendations, but the payments were still refused. Such situations are typical for insurance companies that want to profit from conscientious clients, leaving the latter without payments required by law. However, there are ways to punish them.

In any difficult situation, you have the right to apply to the court. It is necessary to draw up a claim with references to legislative acts or contract lines that were violated by the insurance company. Judicial practice regarding the actions of insurance companies today has a wealth of experience, and therefore you should not leave this matter just like that.

If the insurer refused compensation due to late filing of the application, prove in court that this was a forced measure. However, judicial practice has shown that even in the absence of valid reasons, judges restore the right to compensation.

If the insurance company does not want to pay compensation due to the lack of certain documents, you also have the right to file a complaint about this in court. And in this case, representatives of the law will most likely be on your side and will extend the period for you to comply with the insurer’s requirements.

Filing an application to court is a complex task that can be overwhelming for someone new to the matter. In this matter you need to have experience and some skills. In this regard, it is better to contact law firms to collect funds, which will act as an intermediary between you and the judicial authorities.

Such firms have extensive experience in solving customer problems related to refusal of payments from insurance companies. They will draw up a statement of claim for you, submit it to the judicial authority and will accompany you throughout the entire period of proceedings.

Contacting such firms is also recommended for the reason that insurance companies have a base of their own lawyers who competently draw up contracts and have experience in resolving legal issues. It is very difficult to deal with them on your own, especially if you have never filed a claim before, and especially if you are not strong in legislative issues.

Example of compensation calculation

To make it more clear to you how the final amount of compensation is calculated, we will look at it with examples. Let’s take as a basis an apartment worth 3,400,000 rubles. She is insured for 2,800,000 rubles. The amount of damage amounted to 3,000,000 rubles.

When indemnified based on a percentage, the policyholder will be entitled to the following amount:

• 2800000/3400000 = 0.82 (coefficient by which the amount of damage is multiplied);
• 0.82*3000000 = 2,460,000 rubles.

If the policy specifies a system of payments for the first risk, then the policyholder will receive 2,800,000 rubles, since the amount of damage is greater than the maximum insurance amount (3,000,000>2,800,000).

When a franchise agreement is designated for 100,000 rubles, the owner of the apartment will receive: 2,800,000-100,000 = 2,700,000 rubles.