In order to solve the problems of nonstandard personal injury investigation entry items, unclear and incomplete file uploading, disordered uploading order and nonstandard file filling in the E-insurance claims system, in order to cooperate with the normal development of centralized claims, strengthen post control and improve the quality of personal injury investigators, the following specifications are made for the entry of E-insurance claims system:
A, all cases required (not allowed to blank) include:
1, victim profile section
This part includes name, gender, age, industry, working status, work unit, hospital, number of people needing nursing, diagnosis result, degree of injury, days of hospitalization (in-hospital nursing, days of missed work), days of treatment (out-of-hospital nursing, days of missed work), and whether it is necessary to transfer to hospital for treatment; The specific entry requirements are as follows:
1) Name, gender and age
Fill in according to the valid identity and household registration certificate provided by the injured person, in which the age must be calculated according to the time of the accident and the date of birth of the household registration certificate;
2) Industries engaged in
Fill in according to the industry category standard, fill in according to agriculture if there is no job in agricultural registered permanent residence, fill in according to "none" if there is no job, and fill in according to "retirement" or "resignation" when leaving or retiring;
3) Working conditions
From the perspective of the industry, agricultural registered permanent residence has no labor contract and no fixed income, and has a fixed income when leaving or retiring;
4) Work unit
Fill in according to the actual unit, such as agricultural registered permanent residence, unemployed and retirees, and fill in according to "None";
5) Go to the hospital
Hospitals, departments and beds must be filled in;
6) Number of people needing care
According to the nursing certificate provided by the injured hospital, there is no "0" nursing item;
7) Diagnostic results
It is the final diagnosis result provided by the hospital;
8) degree of injury
According to the diagnosis results combined with the "human injury degree identification standard" to choose;
9) Days of hospitalization
The actually approved days of hospitalization nursing and missed work are determined according to the days of hospitalization and the rest nursing certificate issued by the hospital, and the days of hospitalization are calculated according to the standard of regardless of head and tail, and pay attention to whether there is bed hanging; ;
10) days for treatment.
The time for the injured to arrive at the end of treatment is determined according to the certificate of establishment and rest issued by the hospital and the certificate of out-of-hospital care, which is the standard for verifying out-of-hospital care, days of missed work and days of hospitalization;
1 1) Do you need to be transferred for treatment?
According to the specific injury and the situation at the time of the accident, it is also suitable for outpatient treatment to pay attention to transfer treatment.
2. Injury category part
The specific entry requirements are as follows:
1) This item is a multiple-choice question. Please select the damaged parts according to the contents of the diagnosis results, and you can choose more than one.
2) Damage description
Fill in the cause and process of the injury and the situation that needs treatment or nursing in the future, so as to check the authenticity of the injury.
3. Contact information section
To enter the investigation contact with the victim himself or his family or the insured, there must be actual contact content, and fill in "None" if there is no contact.
4. Cost compensation.
In this part, vehicle license plate number, cost items, responsibilities, description, formula, reported loss amount, excluded amount, estimated loss amount, and investigation opinions of victims; The specific entry requirements are as follows:
1) The license plate number of the victim's vehicle.
Fill in the vehicle number of the victim (fill in the model and frame number of a new or unlicensed vehicle). For non-motor vehicles, you can fill in the name of the vehicle in which the injured person is riding, and pedestrians on the road should fill in "Pedestrian";
2) Expense items
It is necessary to arrange related projects in strict accordance with the list of casualties, and the lost time, nursing expenses and transportation expenses of compulsory insurance can be recorded in the death and disability of each accident;
3) Responsibility project
If you choose the right one within the compensation scope of compulsory insurance, you must first enter the compulsory insurance part. If it does not exceed the compulsory insurance amount, it will be entered according to the actual amount. If it exceeds the compulsory insurance part, it will be entered after deducting the compulsory insurance limit.
4) description
Fill in the content should be the basis of the amount of loss, such as the living expenses of the dependents, and fill in the number and years according to the consumption expenditure of urban or rural residents in a certain year to provide a basis for the formula;
5) Formula
Fill in the requirements according to the description;
6) reported loss amount
It is the total claim amount proposed by the customer, which is decomposed by the insured and entered item by item;
7) Excluding the amount.
It is not the amount of expenses that should be borne by this accident, but should be input according to the actual certificate and bill and the reported loss amount. For example, the dependent person does not meet the conditions for being supported, there is no compensation for mental damages decided by the court, no lost time expenses resulting in income reduction, no nursing expenses for actual nursing, and no claims expenses for providing relevant bills or certificates;
8) Estimated loss amount
Enter the final amount of reported loss minus the excluded amount;
9) Survey opinions
Need to enter the explanation of whether to agree to file a case and the supplementary explanation of returning the case for re-investigation according to the accident investigation;
5. Relevant documents
This part needs to be entered in two parts: claim notice and additional documents; The specific entry requirements are as follows:
1) Notice of Claim
It is necessary to apply for compensation according to the insured's case type, and enter the relevant claims procedure according to the "Motor Vehicle Insurer's Injury Compensation Claims Procedure". When the insured submits an application for claim settlement, two copies shall be printed, which shall be signed by the insured and the insurance company and kept by both parties;
2) Attach documents
When uploading additional documents, the first thing to note is that in the personal injury investigation task, many people should upload relevant claims certificates according to the victim's name; The requirements for uploading files are as follows:
I. Upload order of documents:
Accident confirmation → accident mediation → other documents are uploaded one by one according to the items listed in the casualty loss list. For example, medical expenses related documents are put together (such as medical invoices, lists, diagnosis and inspection certificates, medical records and surgical records, etc.). , the victim's household registration certificate, family member relationship certificate, and the dependent's household registration certificate, etc. Wait. Wait. );
B, upload system file requirements:
It is not allowed to upload photos in batches. Both photos and scanned photos must be clear (when the uploaded system pictures are enlarged to the resolution of 800*600 pixels in the system, the fonts or patterns will not be blurred or jagged). It is required that the document appear in the correct position in the system and all the contents in the document can be displayed. Multi-page content is uploaded in page order, and the order cannot be reversed or misplaced, and there can be no omissions; All paper documents are scanned and uploaded, and photos can be uploaded under special circumstances, but the above requirements must be met;
C, upload file to fill in the requirements:
In order to improve the quality of files and the rate of compensation, all cases involving personal injury must be accompanied by personal injury investigation report (uploaded at the same time when there is a transcript) and a list of casualties. The requirements for filling in are as follows:
Personal injury investigation report and casualty loss list must be truthfully filled in, and there shall be no omissions;
The loss items and amount in the casualty loss list shall be consistent with the relevant catalogue of system compensation expenses;
Personal injury investigation report should be true and effective, which can reflect the injury, income and relevant information of nursing staff;
Personal injury investigation records must be fair and complete, and questions and answers should be to the point.
D. Internal documents of the company that must be uploaded
Danger notice;
Personal injury investigation report;
List of personal injury losses;
Personal injury site investigation records;
Second, fill in the project requirements according to the different actual conditions of the claim project.
1, victim profile section
1) standard salary
A. Enter this item when the claim item involves lost time, disability allowance or family living expenses;
B. The insured indicates that the certificate issued by the hospital where the victim went to see a doctor conforms to the injury, and provides the proof that the victim actually reduced his income due to missing work, such as the income certificate, salary slip or employment contract for three months before the accident. If the income exceeds the standard of paying individual income tax, it is necessary to provide the tax payment certificate or practice certificate of the industry in which it is engaged; Then enter the monthly average salary according to the actual salary of three months, and provide salary certificate, tax payment certificate or no fixed income with reference to the average salary standard of the same industry in the previous year or the per capita net income standard of disposable income of urban households or rural areas; It should be noted that if the payslip contains bonus and allowance income, it should be deducted from the payslip and entered into the corresponding column;
2) Monthly bonus and subsidy (subsidy)
According to the income certificate provided by the insured that the victim actually reduced due to missing work, such as the income certificate (bonus and subsidy) issued three months before the accident, if the income exceeds the personal income tax payment standard, a tax payment certificate is required;
3) Subtotal of monthly income
According to the first two income, add input;
4) Annual bonus, semi-annual bonus, quarterly bonus and attendance bonus.
This part of the entry rarely appears. If the insured provides such proof when providing the income certificate, please contact the personnel injury room of the head office and generally fill in "0";
5) Disability level
Only if it causes disability, the grade shall be selected according to the results of the disability appraisal report issued by the disability appraisal institution;
2. Partial compensation.
1) expense item
If the "Expense Item" and related items are changed and added during the second submission, they will be added after the last item submitted for the first time and cannot be reordered;
2) Survey opinions
For cases submitted twice, you must choose supplementary opinions and explain the supplementary or modified contents;
3. Relevant documents
When relevant certificates need to be added to the attached files, the uploaded contents must be added at the end of all uploaded files, and the file order shall not be changed at will;
Three, according to the "motor vehicle insurer injury compensation procedures" requirements to upload the required claims documents.
Four, all the above items, such as found in the audit process can not meet the standard requirements, will be returned until qualified.
Five, the measures shall be implemented as of the date of issuance, and the standards previously implemented shall be abolished at the same time.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.