Claims Adjuster acting on behalf of the insured
Atua por mandato do segurado para estruturar e defender uma reclamação documentada.
ROUX AFRIQUE CLAIMS · ÁFRICA E MÉDIO ORIENTE
CLAIMS MANAGEMENT
CLAIMS ADJUSTER · CLAIMS ADVOCACY · TPA
MOBILIZAR · QUANTIFICAR · NEGOCIAR · LIQUIDAR
Um grande sinistro não é um simples processo administrativo
A Roux Afrique Claims acompanha empresas seguradas, grupos industriais, instituições e investidores perante sinistros relevantes ou complexos.
Organizamos factos, provas, danos materiais, interrupção de atividade e negociações até ao acordo documentado. Toda delegação TPA permanece sujeita ao mandato, à jurisdição e à matriz de autoridade.
DESDE AS PRIMEIRAS HORAS
O sinistro começa antes de toda a informação estar disponível
Após um evento relevante, a empresa deve agir rapidamente sem fragilizar a reclamação.
Após um evento relevante, a empresa deve agir rapidamente sem fragilizar a reclamação.
- proteger pessoas e ambiente
- proteger instalações e limitar o agravamento
- preservar provas e cronologia
- notificar as partes
- manter operações críticas
- documentar despesas urgentes
- preparar reparação ou substituição
- medir o impacto financeiro
A Roux Afrique Claims equilibra urgência operacional, prova, leitura contratual e controlo financeiro.
Stakeholders
BoardsCEOCOOCFODirections industriellesRisk & Insurance ManagersHSEMaintenanceProductionLegalCourtiersAssureursRéassureursLoss AdjustersLendersInvestisseurs
TRÊS MODELOS DE INTERVENÇÃO
Responsabilidades que não devem ser confundidas
Claims Management end-to-end
Gestão operacional do processo da notificação à liquidação.
TPA & Delegated Claims Administration
Administração delegada num quadro jurídico, contratual e regulatório válido.
The TPA designation grants no implied authority; every power remains subject to the mandate.
GESTÃO DO SINISTRO
Oito workstreams para um processo complexo
Mobilização, segurança e governação
Loss team, decision-makers, approval paths, emergency measures, decision log and initial strategy.
Notificação e arquitetura do programa
Policies, periods, insured interests, deductibles, limits, extensions, coinsurance, fronting, reinsurance and documentary duties.
Preservação de provas e causalidade
Locations, photographs, exhibits, witnesses, logs, maintenance, analyses, chain of custody and established-fact register.
Danos materiais
Buildings, machinery, stocks, safeguarding costs, debris removal, transport, erection, testing, salvage, depreciation and betterment.
Business Interruption e perdas financeiras
Lost capacity, trends, seasonality, gross profit, savings, ICOW/AICOW, mitigation, repair and ramp-up.
Mitigação, reparação e recuperação
Repair or replacement, temporary solutions, outsourcing, long-lead items, permits, commissioning and critical path.
Preparação e negociação da reclamação
Statement of Claim, quantum, evidence reconciliation, memoranda, issue register, interim payments and executive decisions.
Liquidação, encerramento e lições aprendidas
Allocation by coverage, agreement and payment tracking, reserved items, recovery, archiving and prevention recommendations.
METODOLOGIA
Do evento à liquidação em nove etapas
- 01
Mobilizar
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
Estabelecer os factos
Build a sourced chronology and separate facts, statements and assumptions.
- 05
Quantificar
Assess PD, BI, costs and mitigation on explicit bases.
- 06
Documentar
Link each item to evidence, calculations, responsibilities and assumptions.
- 07
Testar
Test technical, contractual, financial and documentary consistency.
- 08
Negociar
Present positions, address gaps and seek a documented agreement.
- 09
Liquidar e 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.
GOVERNAÇÃO POR EXCEÇÕES
Gerir lacunas, não volume 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.
TESOURARIA DE RECUPERAÇÃO
Os adiantamentos não devem esperar pelo fim da peritagem
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.
DELEGAÇÃO CONTROLADA
Um TPA governado por uma matriz de autoridade
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
Uma Data Room estruturada desde as primeiras 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 INDEPENDENTE
Revisão independente antes da apresentação
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.
PROVA DIGITAL
Inventys® e VRA3D ao serviço da rastreabilidade
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.
ENTREGÁVEIS
Entregáveis concebidos para fazer avançar a liquidação
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
Quando mobilizar a 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.
COMPETÊNCIAS SETORIAIS
Setores que exigem especialização
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
Um mandato responsável. Âmbitos 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.
REFERENCIAIS
Referenciais aplicados ao mercado e ao 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.
PERGUNTAS FREQUENTES
Compreender o mandato antes de agir
Qual é a diferença entre o Claims Adjuster do segurado e o perito da seguradora?
The former supports the insured in preparing and advocating the claim; the latter acts under the insurer's mandate.
A Roux Afrique Claims decide a cobertura?
No, except under an explicit and valid delegation. Under an insured-side mandate, the insurer decides coverage.
O mandato pode ir até à liquidação?
Yes. It may include quantification, negotiation, agreement tracking and payment reconciliation; payment authority remains with the authorised party.
A Roux Afrique Claims negoceia com resseguradoras?
It may support technical presentations where the programme and mandates permit, without presuming a direct right of the insured.
Qual é a diferença entre Claims Management e TPA?
Claims Management governs the file; TPA requires a delegation defining authority, limits and oversight.
Quando deve o sinistro ser notificado?
As soon as the policy, law and circumstances reasonably allow; missing details may be supplemented later.
Cada despesa exige aprovação prévia?
Urgent safety measures should not be delayed, but must be documented and notified under the policy.
Pode ser solicitado um adiantamento?
Yes, when part of the loss is evidenced, subject to approval by the authorised party.
Como é tratado o betterment?
It is isolated and assessed against policy terms, technical necessity, depreciation and regulatory requirements.
Como se calcula Business Interruption?
From the actual loss, financial data, trends, savings, mitigation and policy wording.
A Roux Afrique Claims substitui o consultor jurídico?
No. It addresses technical, financial and insurance matters; legal opinions remain with authorised counsel.
Pode ser retomado um processo antigo ou bloqueado?
Yes, subject to available evidence, by reconstructing facts, amounts, positions and blockages.
CLAIMS MANAGEMENT & TPA
Uma reclamação credível assenta na força da demonstração
Share the event, policies, first actions, apparent damage and operational impact. We will define the appropriate governance, expertise, evidence strategy and negotiation framework.
Falar com a Roux Afrique Claims