A claim is a harmful event, regardless of the insured’s will, which causes economic damage, provided for in the contract. In the insurance relationship, it is not a common event, nor does it generate common consequences. On the contrary, the covered claim has particularities that make it unique, even if it resembles thousands of others.
A car crashes. It is a concrete event, which may or may not be a covered claim. The mere fact that a car crashes does not necessarily constitute an event capable of generating compensation for an insurance policy. An essential requirement for setting up the covered claim is the resulting economic loss. A car can crash and not suffer or cause economic damage. In this case, there is no need to talk about compensation for the policy.
Likewise, the car can crash and cause economic damage, but the damage is minor and is within the insurance deductible. Once again, there is no need to talk about compensation, even if it is a covered event. Losses within the deductible are the responsibility of the insured, so they are not indemnified by the insurer.
It may happen that the accident, for the amount, has the damages suffered, but the insurance company does not indemnify because the insurance contracted did not have coverage for collision.
It can also happen that the crash causes damage to third parties, who would be regularly covered, but, again, the insurer does not indemnify them, because the policy does not have civil liability coverage.
The passengers of the vehicle that crashed may suffer serious damage as a result of the collision, but if the insurance has not been contracted with coverage for personal accidents of passengers, again, the insurance company does not indemnify.
Another situation in which the insurer may deny compensation is when it is proved that the driver of the insured vehicle, at the time of the accident, was under the influence of alcohol or drugs.
Each of the above denials has a different specific cause, which authorizes the insurer not to indemnify the claim. And they all happen regularly on the streets and highways of the world. In other words, the fact that a car crashes is not the certainty of the payment of compensation as a result of taking out an insurance policy. For the insurer to indemnify, it is necessary that the event meets the conditions set out in the contract. In other words, that the insurance guarantees the risk, that the policy is in force, that the accident is covered, that it is not characterized as an excluded risk, or that the damage affects uncovered goods.
The insurance contract is a special contract, with unique characteristics, regulated by a series of legal and infra-legal rules to be contracted, applied and indemnify a loss. It is a bilateral, adhesion contract, in which the insured has limited power to change the clauses and conditions imposed by the insurer. This is why the transparent claims adjustment process is so important to determine claim coverage and compensation payment.