Claims Adjuster acting on behalf of the insured
Actúa por mandato del asegurado para estructurar y defender una reclamación documentada.
ROUX AFRIQUE CLAIMS · ÁFRICA Y ORIENTE MEDIO
CLAIMS MANAGEMENT
CLAIMS ADJUSTER · CLAIMS ADVOCACY · TPA
MOVILIZAR · CUANTIFICAR · NEGOCIAR · LIQUIDAR
Un siniestro mayor no es un simple expediente administrativo
Roux Afrique Claims acompaña a empresas aseguradas, grupos industriales, instituciones e inversores ante siniestros mayores o complejos.
Organizamos hechos, pruebas, daños materiales, pérdida de beneficios y negociaciones hasta el acuerdo documentado. Toda delegación TPA queda sujeta al mandato, la jurisdicción y la matriz de autoridad.
DESDE LAS PRIMERAS HORAS
El siniestro comienza antes de disponer de toda la información
Tras un evento mayor, la empresa debe actuar rápido sin debilitar su reclamación.
Tras un evento mayor, la empresa debe actuar rápido sin debilitar su reclamación.
- proteger personas y medio ambiente
- asegurar instalaciones y limitar la agravación
- preservar pruebas y cronología
- notificar a las partes
- mantener operaciones críticas
- documentar gastos urgentes
- preparar reparación o sustitución
- medir el impacto financiero
Roux Afrique Claims equilibra urgencia operativa, prueba, lectura contractual y control financiero.
Stakeholders
BoardsCEOCOOCFODirections industriellesRisk & Insurance ManagersHSEMaintenanceProductionLegalCourtiersAssureursRéassureursLoss AdjustersLendersInvestisseurs
TRES MODELOS DE INTERVENCIÓN
Responsabilidades que no deben confundirse
Claims Management end-to-end
Gestión operativa del expediente desde la notificación hasta la liquidación.
TPA & Delegated Claims Administration
Administración delegada dentro de un marco jurídico, contractual y regulatorio válido.
The TPA designation grants no implied authority; every power remains subject to the mandate.
GESTIÓN DEL SINIESTRO
Ocho workstreams para un expediente complejo
Movilización, seguridad y gobierno
Loss team, decision-makers, approval paths, emergency measures, decision log and initial strategy.
Notificación y arquitectura del programa
Policies, periods, insured interests, deductibles, limits, extensions, coinsurance, fronting, reinsurance and documentary duties.
Preservación de pruebas y causalidad
Locations, photographs, exhibits, witnesses, logs, maintenance, analyses, chain of custody and established-fact register.
Daños materiales
Buildings, machinery, stocks, safeguarding costs, debris removal, transport, erection, testing, salvage, depreciation and betterment.
Business Interruption y pérdidas financieras
Lost capacity, trends, seasonality, gross profit, savings, ICOW/AICOW, mitigation, repair and ramp-up.
Mitigación, reparación y recuperación
Repair or replacement, temporary solutions, outsourcing, long-lead items, permits, commissioning and critical path.
Preparación y negociación de la reclamación
Statement of Claim, quantum, evidence reconciliation, memoranda, issue register, interim payments and executive decisions.
Liquidación, cierre y lecciones aprendidas
Allocation by coverage, agreement and payment tracking, reserved items, recovery, archiving and prevention recommendations.
METODOLOGÍA
Del evento a la liquidación en nueve etapas
- 01
Movilizar
Assemble the team, secure the mandate and establish governance.
- 02
Notificar
Identify policies and record communications.
- 03
Preservar
Protect people, facilities and evidence while limiting deterioration.
- 04
Establecer los hechos
Build a sourced chronology and separate facts, statements and assumptions.
- 05
Cuantificar
Assess PD, BI, costs and mitigation on explicit bases.
- 06
Documentar
Link each item to evidence, calculations, responsibilities and assumptions.
- 07
Contrastar
Test technical, contractual, financial and documentary consistency.
- 08
Negociar
Present positions, address gaps and seek a documented agreement.
- 09
Liquidar y capitalizar
Track approvals and payments, close the file and capture lessons learned.
Every material amount must link to a fact, damage, calculation basis, supporting document and documented coverage position.
GOBIERNO POR EXCEPCIONES
Gestionar brechas, no volumen documental
Registers structure amounts, positions, decisions and uncertainties.
Claim Register
Initial, updated, agreed, disputed and paid amounts; evidence, owner, status and next action.
Claim Issue Register
Party positions, factual and policy basis, financial impact, expected decision and deadline.
Decision & Communication Log
Safeguarding measures, approvals, commitments, communications, reservations and provisional agreements.
Data Gap & Assumption Register
Missing or conflicting information, assumptions, sensitivity and remediation action.
TESORERÍA DE RECUPERACIÓN
Los anticipos no deben esperar al final del peritaje
An interim payment request can be prepared when part of the loss is sufficiently evidenced and undisputed.
- amount requested and relevant coverages
- items already evidenced
- committed expenditure and cash-flow requirements
- reservations on open items
- supporting evidence
- reconciliation with earlier interim payments
The payment decision remains with the insurer or authorised party.
DELEGACIÓN CONTROLADA
Un TPA gobernado por una matriz de autoridad
The matrix defines what may be executed, recommended, authorised or escalated.
- claim categories, territories and coverages
- information-request and expert-appointment powers
- recommendation, approval and escalation thresholds
- reserving rules and settlement conditions
- payment process and antifraud controls
- sanctions, embargoes and data protection
- customer complaints and conflicts of interest
- SLA, reporting, audit rights and business continuity
No authority is presumed; anything beyond delegation is referred to the principal.
DATA ROOM
Una Data Room estructurada desde las primeras horas
Depending on the loss, the team assembles operational, technical, financial and policy records.
- policies, endorsements, schedules and notifications
- incident reports, chronology, photographs and videos
- drawings, diagrams, SCADA/DCS, alarms and event logs
- authority reports, causation analyses and maintenance records
- Asset Registers, Statement of Values and purchase invoices
- quotes, orders, invoices, payments and timesheets
- stock, production, sales, budgets and forecasts
- management accounts, BI calculations and mitigation measures
- supplier and customer contracts and reconstruction programme
- minutes, issue registers and agreements
Access is governed by data sensitivity, confidentiality and party rights.
QA/QC INDEPENDIENTE
Control independiente antes de presentar
The review tests factual, technical, financial, policy and documentary coherence.
- mandate compliance and chronology consistency
- source traceability and separation of facts and assumptions
- causation for each claim item
- absence of double counting
- quantities, unit prices, taxes and currencies
- salvage, depreciation and betterment
- PD and BI consistency
- savings, mitigation, ICOW and AICOW
- deductibles, limits and sublimits
- interim-payment calculations and version reconciliation
- Statement of Claim and appendix consistency
- qualification of uncertainty and independent review
A claim is not presented as final while material investigations or decisions remain open.
PRUEBA DIGITAL
Inventys® y VRA3D al servicio de la trazabilidad
Technology organises and spatialises evidence without deciding coverage.
Inventys®
Structures the claim file and its progress.
- items, evidence and damaged assets
- costs, responsibilities and open issues
- versions, interim payments and amounts
- closure evidence and multi-site consolidation
VRA3D
Creates a spatial record of the loss.
- site configuration and damaged areas
- equipment location
- visible extent of damage
- progress and changes during the works
VRA3D does not replace testing, causation analysis or specialist inspection.
ENTREGABLES
Entregables diseñados para avanzar la liquidación
Depending on the mandate:
- 01Immediate Action Plan
- 02Claims Management Protocol
- 03consolidated chronology
- 04Coverage & Notification Matrix
- 05Claim Strategy Memorandum
- 06Evidence Preservation Register
- 07Property Damage Assessment
- 08Business Interruption Assessment
- 09Mitigation Register
- 10Statement of Claim
- 11Claim Register & Claim Issue Register
- 12Data Gap & Assumption Register
- 13interim-payment submissions and supporting files
- 14negotiation presentations and periodic reports
- 15financial dashboard and photographic file
- 16claim–agreement–payment reconciliation
- 17Settlement & Closure Report
- 18lessons learned and recommendations
MOMENTOS DECISIVOS
¿Cuándo movilizar Roux Afrique Claims?
- immediately after a major loss
- when business continuity is threatened
- when several sites, countries, policies or insurers are involved
- for coinsurance or international programmes
- when causation or quantum is complex
- when a material interim payment must be prepared
- when expert discussions stall
- when an old or blocked claim must be restructured
- to outsource a claim portfolio
- before closing items that remain reserved
Late mobilisation may remain possible but cannot recreate evidence that was not preserved.
EXPERIENCIA SECTORIAL
Sectores que exigen especialización
Teams are assembled around damage type, technology, coverage, financial stakes and jurisdiction.
Energy & UtilitiesOil, Gas & PetrochemicalsMining, metals & materialsIndustry & ManufacturingAgri-industryInfrastructureTransport, ports & logisticsTelecommunications & Data InfrastructureReal estate, hospitality & major portfoliosHealthcare & critical servicesConcessions & PPPFinancial institutionsMulti-site portfolios
Technical and financial depth is calibrated to the actual significance of the claim.
ESPECIALIDADES DISTINTAS
Un mandato responsable. Alcances distintos.
Roux Afrique Claims
Structures facts, evidence, damage, loss, claim submissions and post-loss negotiations.
Roux Afrique EVS — Valuation
Provides reconstruction or replacement bases when appointed; a pre-loss value does not automatically determine indemnity.
Roux Afrique EVS — Business Interruption
Establishes pre-loss BI values, dependencies and periods; Claims quantifies the loss actually sustained after the event.
Roux Afrique EVS — Engineering Risk Survey
Assesses hazards and protections before loss; post-loss investigation requires a separate mandate.
Roux Afrique Advisory
Addresses programme architecture, Risk Financing and governance; Claims manages the event once it has occurred.
Roux Cyber & legal counsel
Roux Cyber acts as Cyber Claims Adjuster and coordinates specialist digital investigation; legal opinions, litigation and arbitration remain with authorised counsel.
REFERENCIAS
Referencias aplicadas según mercado y mandato
The policy, endorsements, applicable law, facts and authorised decisions remain decisive.
- 01CIMA Code where applicable
- 02national insurance regulation
- 03programme contractual rules
- 04market Claims Management Principles
- 05coinsurance and Claims Agreement procedures
- 06rules governing TPAs or Delegated Claims Administrators
- 07sanctions, KYC and antifraud requirements
- 08accounting, tax and data-protection rules
Reference to a market standard grants no licence.
An advisory mandate creates no regulated decision or payment authority.
PREGUNTAS FRECUENTES
Entender el mandato antes de actuar
¿En qué se diferencia el Claims Adjuster del asegurado del perito del asegurador?
The former supports the insured in preparing and advocating the claim; the latter acts under the insurer's mandate.
¿Decide Roux Afrique Claims la cobertura?
No, except under an explicit and valid delegation. Under an insured-side mandate, the insurer decides coverage.
¿Puede el mandato llegar hasta la liquidación?
Yes. It may include quantification, negotiation, agreement tracking and payment reconciliation; payment authority remains with the authorised party.
¿Negocia Roux Afrique Claims con los reaseguradores?
It may support technical presentations where the programme and mandates permit, without presuming a direct right of the insured.
¿En qué se diferencian Claims Management y TPA?
Claims Management governs the file; TPA requires a delegation defining authority, limits and oversight.
¿Cuándo debe notificarse el siniestro?
As soon as the policy, law and circumstances reasonably allow; missing details may be supplemented later.
¿Debe aprobarse previamente cada gasto?
Urgent safety measures should not be delayed, but must be documented and notified under the policy.
¿Puede solicitarse un anticipo?
Yes, when part of the loss is evidenced, subject to approval by the authorised party.
¿Cómo se trata el betterment?
It is isolated and assessed against policy terms, technical necessity, depreciation and regulatory requirements.
¿Cómo se calcula Business Interruption?
From the actual loss, financial data, trends, savings, mitigation and policy wording.
¿Sustituye Roux Afrique Claims al asesor jurídico?
No. It addresses technical, financial and insurance matters; legal opinions remain with authorised counsel.
¿Puede retomarse un expediente antiguo o bloqueado?
Yes, subject to available evidence, by reconstructing facts, amounts, positions and blockages.
CLAIMS MANAGEMENT & TPA
Una reclamación creíble depende de la fuerza de su demostración
Share the event, policies, first actions, apparent damage and operational impact. We will define the appropriate governance, expertise, evidence strategy and negotiation framework.
Hablar con Roux Afrique Claims