Claims Management Policy & Procedures

1. Policy Statement

Zamzam Takaful Insurance Company (the “Company”) is committed to administering and settling insurance claims in a fair, transparent, timely, and professional manner, in strict compliance with applicable laws and regulatory requirements.

This Policy establishes the governance framework, control standards, and procedural requirements governing the receipt, assessment, approval, settlement, and monitoring of all insurance claims arising under policies issued by the Company.

2. Legal and Regulatory Framework

This Policy is issued in accordance with:

• Law No. (125) of 2019 regulating insurance activities.
• The Executive Bylaw and any amendments.
• Relevant resolutions and circulars issued by the Insurance Regulatory Unit.
• Applicable resolutions governing motor claims and compulsory insurance.
• Anti-Money Laundering (AML) and Counter-Terrorist Financing (CTF) legislation.
• Corporate governance and internal control requirements applicable to licensed insurance companies.

In the event of any regulatory amendment, this Policy shall be deemed automatically aligned and shall be updated accordingly.

3. Objectives

The objectives of this Policy are to:

• Ensure full regulatory compliance in the management and settlement of claims.
• Safeguard the rights of policyholders, beneficiaries, and third parties.
• Ensure claims are handled within statutory and contractual timeframes.
• Promote consistency, fairness, and objectivity in claims assessment.
• Establish effective segregation of duties and internal control mechanisms.
• Mitigate operational, financial, and fraud risks associated with claims processing.
• Enhance service quality and customer satisfaction.

4. Scope of Application

This Policy applies to all claims arising from insurance contracts issued by the Company, including but not limited to:

• Medical Insurance (Individual and Group)
• Fire and General Accident Insurance
• Marine and Aviation Insurance
• Motor Insurance (Compulsory Third-Party Liability and Comprehensive)
• Any additional lines of business licensed by the regulator

This Policy is binding upon all relevant departments, employees, and any outsourced service providers involved in claims handling.

5. Governance and Segregation of Duties

The following governance structure is maintained:

• The Claims Department shall be responsible for technical assessment and recommendation of settlement.
• Approval of claims shall be exercised strictly in accordance with the Delegation of Authority Matrix approved by Management and/or the Board.
• The Finance Department shall be solely responsible for processing and executing payments upon receipt of duly approved claim documentation.
• No individual shall exercise end-to-end control over claim registration, assessment, approval, and payment.
• The Internal Audit Department shall conduct periodic independent reviews of claims files and processes.
• Senior Management shall receive periodic reports on claims performance indicators.

6. General Principles of Claims Handling

• Immediate registration of claim notification in the approved core system with assignment of a unique reference number.
• Issuance of written acknowledgment of claim receipt.
• Establishment of adequate technical reserves in accordance with actuarial and accounting standards.
• Periodic review and adjustment of reserves as claim developments occur.
• Prompt request for additional documentation where required.
• Clear, reasoned, and documented decisions in cases of partial settlement or rejection.
• Strict adherence to policy terms, conditions, exclusions, deductibles, and limits.
• Implementation of fraud detection and prevention controls.
• Proper documentation and secure archiving of all claim-related records.

7. General Claims Processing Procedures

7.1 Claim Notification and Registration

Upon notification of loss, the claim shall be recorded immediately in the system. A required documentation checklist shall be communicated to the claimant, and a claim file (electronic and/or physical) shall be opened.

7.2 Assessment and Investigation

The Claims Department shall verify the validity and effective period of the policy, coverage applicability, compliance with policy conditions, and the extent of the loss. Where necessary, loss adjusters or technical experts shall be appointed.

7.3 Settlement and Approval

Compensation shall be calculated in accordance with policy terms. The claim shall be submitted for approval as per the Delegation of Authority. Approved claims shall be recorded in the accounting system before forwarding to Finance.

7.4 Payment

The Finance Department shall verify approval, process payment within regulatory timeframes, and ensure AML/CTF screening prior to disbursement.

8. Line of Business Specific Procedures

8.1 General Takaful (Non-Medical)

Includes Fire, General Accidents, Marine & Aviation, and Motor (Comprehensive). This involves the appointment of loss adjusters where required and the establishment of technical reserves with periodic reviews.

8.2 Group Medical Insurance

A. Direct Billing System: Submission within policy timeframe (typically 15 days); referral to TPA for medical assessment.

B. Reimbursement Claims: Review of documents and policy compliance; TPA consultation where required.

C. TPA Hospital Claims: Reconciliation of invoices with approved authorizations; system registration and payment approval.

8.3 Motor Claims

• Settlement within the maximum regulatory period (not exceeding ten (10) working days from completion of required documentation).
• Immediate notification to the claimant upon approval.

9. Reporting and Record Retention

The Claims Department shall prepare periodic reports including outstanding claims analysis for Senior Management. All claim files shall be retained for the legally prescribed period in accordance with regulatory requirements.