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Proper conduct of the claim adjustment process is the responsibility of the insurer, on whom the legislator has imposed certain obligations. In liquidation proceedings, the insurer may not limit itself to merely passively waiting for the insured to submit evidence; He must act actively to clarify all the circumstances of the case. Liquidation proceedings are not at the same time contentious proceedings in which the burden of proof could function within the meaning of Article 6 of the Civil Code. It is the insurer’s task to assess the legitimacy of the injured party’s claims.

Winding-up framework

The essence of the liquidation proceedings is to determine whether the insurance company is liable for damage resulting from a fortuitous event that is covered by insurance. Within 7 days from the moment of notification of the occurrence of such an event, the insurer is obliged to commence liquidation proceedings and inform the policyholder or the insured of the receipt of the loss notification. During this time, the employer should also indicate what documents are necessary to determine the benefit and liability of the insurance company. The liquidation proceedings include:

1. determination of the facts;

2. assessment of the legitimacy of the submitted claims; 3. determination of the amount of the benefit due.

The insurer must act on its own

In the course of the liquidation proceedings, the insurer may not limit itself to passively waiting for the injured party to present all the evidence himself; On the contrary, he should be the leader of this process, taking actions necessary to determine the circumstances of the event and the legitimacy of the claim. The insurer may not demand any documents, but only, as indicated above, the necessary ones. The insurer may also not demand documents that would be excessively burdensome for the person filing the claim. Finally, the insurer cannot wait for the injured party to prove that a specific event occurred or suspend its activities until the court has made a final decision. In other words, it cannot wait for the end of criminal proceedings, a court verdict or an expert’s opinion.

After the liquidation procedure, the insurance company informs the injured party in writing about its outcome, indicating whether it accepts the claim or refuses to pay benefits.

Deadline for payment of compensation and information obligations

The insurer is obliged to pay the benefit within thirty days from the moment of receiving notification of the accident. However, if it is impossible to clarify the circumstances necessary to determine the insurer’s liability or the amount of the benefit within that period, the benefit should be paid within 14 days from the date on which it was possible to clarify these circumstances with due diligence. The above means that a delay in performance may be justified only if the insurer demonstrates that there were obstacles preventing the explanation of the circumstances necessary to determine liability or the amount of the benefit, despite the insurer’s actions taken with special care. If the insurer fails to demonstrate these reasons, it falls into delay, which entitles the person filing the claim to claim interest. In the event of refusal to pay or determination of a different amount of the benefit than the submitted claim, the insurer is obliged to indicate in writing the circumstances and legal basis of this decision and inform about the possibility of pursuing claims in court. It should be mentioned that when justifying the issued decision, the insurer cannot limit itself to general or laconic statements. On the contrary, it is obliged to present in detail and precisely the findings made in the liquidation proceedings, so as to ensure that the entitled party has a reliable assessment of the legitimacy of the decision.

You can appeal against the insurer’s decision

The insurer is not liable for damage caused intentionally by the policyholder (and in the case of an insurance contract on someone else’s account also by the insured). In the event of gross negligence, compensation is also not due, unless the contract or the general terms and conditions of insurance provide otherwise, or if the payment of compensation corresponds to equity considerations in the circumstances. Under civil liability insurance, it is possible to establish other rules of the insurer’s liability than those specified above, which means that liability for damage caused intentionally or as a result of gross negligence may be assumed in the insurance contract.

Claims arising from the insurance contract are property claims, and therefore they are subject to the statute of limitations. Pursuant to Article 819 § 1 of the Civil Code, the limitation period is 3 years. This provision is mandatory, which means that the parties may not introduce different regulations in the insurance contract or in the general terms and conditions of insurance. At the same time, the limitation period begins to run from the date on which the claim would have become due if the entitled party had notified the accident at the earliest possible date.

Financial Ombudsman and legal action

If the insurer refuses to pay compensation or its decision does not meet the expectations of the insured, it is possible to submit an application (complaint) to the Financial Ombudsman. The Ombudsman, after reviewing the case, may take various actions, m.in. take part in the case, ask the financial market entity to reconsider the case, and indicate to the applicant his rights and means of action. It may also indicate the possibility of using out-of-court proceedings for the settlement of disputes between the client and the financial market entity.

If the Ombudsman’s intervention does not bring a satisfactory result, the aggrieved party may refer the case to court. In such a case, it is important to remember about the applicable limitation periods and to carefully prepare documentation and evidence that will be relevant to the trial.

It is worth using professional help

Already at the time of reporting the damage, it is worth considering cooperation with professional attorneys (legal advisor, advocate). Their involvement often prompts insurers to consider their decisions more carefully. Thanks to the experience of attorneys, it is also possible to precisely assess the legitimacy of the insurer’s position, which undoubtedly affects the successful conclusion of the case.