Procedure for the Review of Claims
A frequently asked question on our Claims Class training courses is “how should the engineer (or other party responsible for responding to a claim) ensure that he is being fair to both parties when making a decision or determination?”
In my experience, claim submissions range from totally inadequately expressed claims to very well-presented documents but on balance, I have to say that the majority tend to be in the former category. Over the years, in situations where I am responsible for producing a response, I have developed the following procedure for dealing with claims of all shapes and sizes.
- Undertake an initial review of the claim;
- Advise the claimant of any shortcomings, which prevent the reviewer from reaching a determination. This could be through formal queries or requests for additional information. If the claim is totally inadequately expressed, it may be appropriate to reject the claim at this stage on the basis that entitlement is not proved. In such a case, it would also be proactive to set out what information should be included in a resubmission in order that a proper review may be undertaken;
- Following receipt of additional particulars or a revised claim submission, review the claim and proceed with an assessment based on the information provided;
- Issue a detailed response document to both parties that sets out the findings. It is important to bring the employer into the process at this point, because his agreement to the findings will ultimately be required and this will provide an opportunity for him to raise queries or objections or to state his point of view;
- After a suitable time for review by the parties, meet with the parties to accept comments, either at the meeting or later in writing as is appropriate;
- Make any revisions to the response document that are appropriate following the receipt of comments and issue the revised assessment to the parties for review and comment;
- Repeat the issue/meet/comments process if necessary until agreement is reached;
- If no agreement is reached, proceed with a determination and issue a fully detailed and substantiated document to set out the findings.
The above procedure also discourages the claimant from submitting poor claim documents, because he will soon learn that if a favourable determination is to be issued within a reasonable time frame, he must provide the reviewer with all the information necessary to perform a proper review in the initial claim document.