TANZANIA INSURANCE REGULATORY MAMLAKA YA USIMAMIZI WA BIMA TANZANIA

AUTHORITY

GUIDELINES ON INSURANCE CLAIMS MIONGOZO YA KUSHUGHULIKIA MADAI YA

MANAGEMENT BIMA

Version No. 1.0 Toleo Na. 1.0

SEPTEMBER, 2022 SEPTEMBA, 2022

TABLE OF CONTENTS YALIYOMO
SECTION ONE: INTRODUCTION SEHEMU YA KWANZA: UTANGULIZI
1.1 Authorization and Powers……………………………….……1 1.1 Idhini na Mamlaka…………………………………………...1
1.2 Citation………………………………………………….………1 1.2 Nukuu………………………………………………………....1
1.3 Background and Rationale……………………………………1 1.3 Usuli na Mantiki………………………………………………1
1.4 Application and Scope…………………………………………2 1.4 Matumizi na Mawanda……………………………………....2
1.5 Purpose and Objectives……………………………….………2 1.5 Lengo na Madhumuni………………………………..………2
1.6 Definitions and Acronyms ….………………………….…......3 1.6 Maana ya maneno na Vifupisho….…………….…………..3

SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA KUSHUGHULIKIA
INSURANCE CLAIMS MADAI YA BIMA
2.1 Kanuni za Kuzingatia Katika Kushughulikia Madai……….....3
2.1 Principles to be Observed in Claims Management ..............3
2.2 Jukumu la Kampuni ya Bima Kwenye Kushughulikia Madai..3
2.2 Role of an Insurer in Claims Management ………………….4
2.3 Wajibu wa Watuwakati katika Usimamizi wa Madai………….6
2.3 Role of Intermediaries in Claims Management ……………..6
2.4 Ushughulikiaji wa Migogoro ya Madai………………………….6
2.4 Handling of Claims Disputes ………………………………….6
2.5 Upatikanaji wa Kazi za Madai kutoka Nje……………………...7
2.5 Outsourcing of Claims Management Functions …………….7

SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI

SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF
ZA KUSHUGHULIKIA MADAI
CLAIMS PROCESSING 3.1 Kutoa Taarifa ya Madai…………………………………………….8
3.1 Claims Notification ……………………………………………..8 3.2 Kukiri Kupokea ……………………………………………………..9
3.2 Acknowledgement………………………………………………9 3.3 Kukubalika kwa Madai ……………………………………………12
3.3 Admissibility of Claims ………………………………………..12 3.4 Uteuzi wa Mtoa Huduma………………………………………….13
3.4 Appointment of Service Provider …………………………….13 3.5 Kutolewa kwa Hati ya Kuridhia Malipo…………………………..14
3.5 Issuance of Discharge Voucher………………………………14 3.6 Ulipaji wa Madai…………………………………………………....14
TABLE OF CONTENTS YALIYOMO
3.6 Payment of Claims……………………………………………..14

SECTION FOUR: PROHIBITED PRACTICESs SEHEMU YA NNE: MAMBO YALIYOPIGWA MARUFUKU

4.1 Prohibited Practices…………………………………………....16 4.1 Mambo Yaliyopigwa Marufuku………………………………..….16

SECTION FIVE: SUPERSION AND MONITORING SEHEMU YA TANO: USIMAMIZI NA UFUATILIAJI

5.1 Utoaji Taarifa ya madai………………………………..................17
5.1 Reporting Requirements………………………………………17
5.2 Utunzaji dfwa Kumbukumbu………………………………………17
5.2 Record Keeping………………………………………..……....17
5.3 Utekelezaji wa Kisheria……………………………………………19
5.3 Legal Enforcement…………….………………………..…......19

SEHEMU YA SITA: MAPITIO NA IDHINI YA MIONGOZO

SECTION SIX: REVIEW AND APPROVAL
6.1 Mapitio ya Miongozo………………………………………………20
6.1 Review ………………………………………..........................20
6.2 Tarehe ya kuanza kutumika……………………………………....20
6.2 Effective date…………………………………………………...20
6.3 Imeidhinishwa…………………………………..……………….….20
6.3 Approved ……………………………………………………….20
 SECTION ONE: INTRODUCTION SEHEMU YA KWANZA: UTANGULIZI
1.1 Authorizatio These Guidelines are issued pursuant to Section 6 1.1 Idhini na Miongozo hii imetolewa kwa mujibu wa Kifungu cha 6
n and (2) (e) and 11 (b) of the Insurance Act Cap 394 Mamlaka (2) (e) na 11 (b) cha Sheria ya Bima Sura Na. 394
Powers which mandate the Authority to formulate ambacho kinaiagiza Mamlaka kuweka vigezo vya
standards in the conduct of the business of uendeshaji wa shughuli za bima ambavyo vitatakiwa
insurance w6thich shall be observed by insurance kuzingatiwa na watoa huduma za bima.
registrants.
1.2 Citation These Guidelines may be cited as “Guidelines on 1.2 Nukuu Miongozo hii itafahamika kama “Miongozo ya
Insurance Claims Management, 2022” Kushughulikia Madai ya Bima, 2022”
1.3 Background 1.3.1 These Guidelines seek to address the market 1.3 Usuli na 1.3.1 Miongozo hii imetokana na hitaji la kuboresha
and need of improving insurance claims management Mantiki mifumo ya ushughulikiaji madai ya bima kwenye soko
Rationale services which is necessary for enhancement of la bima, jambo ambalo ni muhimu katika kujenga imani
public confidence on insurance services. ya wananchi kwa huduma za bima.

1.3.2 Whereas, Section 131 of the Insurance Act 1.3.2 Japokuwa Kifungu cha 131 cha Sheria ya Bima
requires an insurer to pay claims within forty-five kinaitaka kampuni ya bima kulipa madai ya bima ndani
(45) days of date of receipt of the executed ya siku arobaini na tano (45) tangu tarehe ya kusainiwa
discharge, the Act has not stipulated time limits for hati ya kuridhia malipo, sheria haijaweka ukomo wa
other stages of claims management, thus hatua zingine za kushughulikia madai kabla ya
occasioning unnecessary delays in Turnaround kutolewa kwa hatia ya kuridhia malipo, hivyo
Time for processing of legitimate insurance claims

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 kusababisha uchelewashaji usio wa lazima wa
1.3.3 The Guidelines are intended to establish an kushughulikia madai halali ya bima.
effective mechanism for Turnaround Time for 1.3.3 Miongozo hii inakusudia kuweka utaratibu
processing and settlement of insurance claims in madhubuti wa muda wa kushughulikia madai ya bima
line with the industry best practice as stipulated kwa hatua mbalimbali kuanzia kutolewa kwa taarifa ya
under Section 131 (3) of the Act. janga hadi kufanyika kwa malipo. Hii inazingatia
mwenendo bora wa kushughulikia madai ya bima
kulingana na Kifungu 131 (3) cha Sheria ya Bima.
1.4 Application These Guidelines shall apply to: 1.4 Matumizi na Miongozo hii itawahusu:
and Scope i. Registrants licensed by the Authority to Mawanda i. Taasisi zilizosajiliwa na kupewa leseni na Mamlaka
provide insurance services; and kutoa huduma za bima; na
ii. Insurance customers, beneficiaries, and other ii. Wateja wa bima, wanufaika, na wadau wengine wa
relevant stakeholders of insurance huduma za bima.
services.
1.5 Purpose and 1.5.1 To establish a mechanism of regulating and 1.5 Lengo na 1.5.1 Kuweka utaratibu wa kudhibiti na kusimamia
Objectives supervising Turnaround Time for Madhumuni muda wa kushughulikia na kulipa madai ya
processing and settlement of claims. bima.
1.5.2 To improve customer experience in terms 1.5.2 Kuboresha uzoefu wa wateja wa bima kwa
of timeliness of processing and settlement kusimamia na kuzingatia ipasavyo muda wa
of claims, thus maintaining their economic uchakataji na ulipaji wa madai, hivyo
and social status. kuimarisha hali zao za kiuchumi na kijamii.
1.5.3 To improve public confidence in insurance 1.5.3 Kuongeza imani ya umma katika huduma za
services. bima.

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1.6 Definitions Act: means the Insurance Act Cap 394 1.6 Maana na Sheria: maana yake ni Sheria ya Bima Sura ya 394
and Authority: means Tanzania Insurance Regulatory Vifupisho vya Mamlaka: maana yake ni Mamlaka ya Usimamizi wa
Acronyms Authority established under the Insurance Act. maneno Bima Tanzania iliyoanzishwa chini ya Sheria ya Bima.

Commissioner: means the Commissioner of Kamishna: maana yake ni Kamishna wa Bima

Insurance appointed under Section 7 of the aliyeteuliwa chini ya Kifungu Namba 7 cha Sheria ya
Insurance Act. Bima.

Service provider: for purposes of these Mtoa huduma: kwa minajili ya miongozi hii, ‘mtoa
Guidelines a ‘service provider’ shall mean a huduma’ itamaanisha taasisi iliyosajiliwa na Mamlaka
registrant involved in claim processing. na inayojihusisha na ushughulikiaji madai ya bima.
TAT: Means Turnaround Time.
TAT: inamaanisha muda wa kushughulikia madai ya
TZS: Means Tanzania Shillings. bima

TZS: Maana yake ni Shilingi ya Tanzania.

SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA USHUGHULIKIAJI WA
INSURANCE CLAIMS MADAI YA BIMA
2.1 Principles to 2.1.1 Insurers shall handle claims in a timely, fair 2.1 Kanuni za 2.1.1 Kampuni za bima zitashughulikia madai kwa
be Observed and transparent manner. Kuzingatia wakati, haki na kwa uwazi.
in Claims 2.1.2 Insurers shall have fair and transparent claims katika 2.1.2 Kampuni za bima zitaweka sera na taratibu
Management handling and claims dispute resolution policies and Ushughulikiaj za haki na uwazi katika kushughulikia madai na
procedures in place. i Madai kusuluhisha migogoro.
2.1.3 Subject to these Guidelines, insurers shall 2.1.3 Kwa kuzingatia Miongozo hii, kampuni za
maintain written documentation on their claims bima zitapaswa kuweka kwa maandishi taratibu za
handling procedures, which include all steps from the kushughulikia madai ambazo zitajumuisha hatua

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SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA USHUGHULIKIAJI WA
INSURANCE CLAIMS MADAI YA BIMA
claim being raised to its settlement. Such zote kuanzia kupokelewa kwa madai hadi kulipwa.
documentation may include expected timeframes for Taratibu hizo zitajumuisha muda unaotarajiwa
relevant steps, which might be extended in kutumika kwa kila hatua, ambao utaweza
exceptional cases. kuongezwa inapobidi.
2.1.4 Claimants shall be informed about 2.1.4 Wadai watafahamishwa kuhusu taratibu
procedures, formalities and common timeframes for rasmi na muda wa kawaida wa ulipaji wa madai.
claims settlement. 2.1.5 Wadai watapewa taarifa kuhusu hatua
2.1.5 Claimants shall be given information about the iliyofikiwa katika ushughulikiaji wa madai yao kwa
status of their claim in a timely and fair manner. wakati na kwa haki.
2.1.6 Claim-determinative factors such as 2.1.6 Vigezo vya uthaminishaji madai kama vile
depreciations, discounting, excess or negligence kushuka kwa thamani, punguzo, kiasi ambacho
shall be illustrated and explained in comprehensive kitachangiwa na mteja au uzembe vitaonyeshwa na
language to claimants. The same applies where kufafanuliwa kwa ufasaha. Vigezo hivyo vitatumika
claims are denied in whole or in part. pale ambapo madai yatakataliwa kwa ujumla au
kwa sehemu.

2.2 Role of an 2.2.1 An insurer shall play a major role in the 2.2 Jukumu la 2.2.1 Kampuni ya bima itakuwa na jukumu la
Insurer in implementation of these guidelines. In this regard, the Kampuni ya msingi katika utekelezaji wa miongozo hii. Katika
Claims insurer shall ensure the following are in place at all Bima hili, kampuni ya bima itahakikisha yafuatayo
Management times: Kwenye yanafanyika wakati wote:
2.2.2 An insurer shall have a secured and properly Kushughuli 2.2.2 Kampuni ya bima itakuwa na mfumo salama
functioning system that keeps records of all reported kia Madai na unaofanya kazi ipasavyo ambao unatunza
claims. kumbukumbu za madai yote yaliyoripotiwa.

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SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA USHUGHULIKIAJI WA
INSURANCE CLAIMS MADAI YA BIMA
2.2.3 An insurer shall have a claims desk. 2.2.3 Kampuni ya bima itakuwa na dawati la
2.2.4 An insurer shall have a toll-free number or madai.
other means of communication for reporting of 2.2.4 Kampuni ya bima itakuwa na nambari ya
insurance claims, which shall be available for use 24 simu isiyolipishwa au njia nyingine ya mawasiliano
hours a day/ 7 days a week. ya kuripoti madai ya bima, ambayo itapatikana kwa
2.2.5 An insurer shall ensure that each of its saa 24 kwa siku/siku 7 kwa wiki.
policyholders is well informed on modalities for 2.2.5 Kampuni ya bima itahakikisha kwamba kila
reporting of insurance claims including regarding its mmiliki wa mkataba wa bima anafahamishwa vyema
claims desk and its toll-free number for reporting of kuhusu taratibu za kuripoti madai ya bima ikiwa ni
claims. This information shall be given at pamoja na kuhusu dawati lake la madai na nambari
commencement and renewal of an insurance cover. yake ya kutoza malipo ya kuripoti madai. Taarifa hii
2.2.6 An insurer shall harness claims Turnaround itatolewa wakati wa kuanza na kuhuisha bima.
Time (TAT) as a key indicator towards service 2.2.6 Kampuni ya bima itatumia muda wa
excellence. kushughulikia madai kama kiashirio kikuu cha ubora
2.2.7 An insurer shall establish effective policies wa huduma.
and procedures for claims management which shall 2.2.7 Kampuni ya bima itaweka sera na taratibu
address the minimum expectations with regard to madhubuti za usimamizi wa madai ambazo
claims reporting, class assessment, claims discharge, zitaonesha matarajio ya chini kuhusu kuripoti madai,
and claims settlement. tathmini, na ulipaji wa madai.
2.2.8 An insurer shall establish a well-resourced 2.2.8 Kampuni ya bima itaanzisha idara/kitengo
claims department/unit with clear goals including cha madai chenye rasilimali na malengo yaliyo wazi
relating to claims TAT. ikiwa ni pamoja na yanayohusiana na TAT.

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SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA USHUGHULIKIAJI WA
INSURANCE CLAIMS MADAI YA BIMA
2.2.9 Where a need arises, an insurer shall utilize 2.2.9 Pale inapohitajika, Kampuni ya bima
the services of registered claims assessors who shall itatumia huduma za wakaguzi wa madai
adhere to performance standards, including relating waliosajiliwa ambao watazingatia viwango vya
to claims TAT. utendaji, ikiwa ni pamoja na TAT.
2.2.10 An insurer shall maintain total responsibility 2.2.10 Kampuni ya bima itakuwa na jukumu la
for processing insurance claims, including jumla la kushughulikia madai ya bima, ikijumuisha
observance of claims TAT, throughout the claim uzingatiaji wa TAT, katika kipindi chote cha
processing cycle uchakataji wa madai.
2.2.11 An insurer shall give to the relevant claimant/ 2.2.11 Kampuni ya bima itampa mdai/mnufaika
beneficiary claim progress feedback at least once husika mrejesho wa maendeleo ya dai/madai
every week by using a convenient means of angalau mara moja kila wiki kwa kutumia njia rahisi
communication including the claimant’s registered ya mawasiliano ikijumuisha nambari ya simu ya
mobile phone number and/or email address until such kiganjani iliyosajiliwa ya mdai na/au barua pepe hadi
date the claim is fully executed. tarehe madai yatakapolipwa.
2.3 Role of 2.3.1 Intermediaries may sometimes serve as an 2.3 Wajibu wa 2.3.1 Watu wa kati wanaweza kutumika kama
Intermediarie initial contact for claimants, in the common interest of Watuwakati mawasiliano ya awali kwa wadai, kwa maslahi ya
s in Claims the policyholder, intermediary and insurer. katika pamoja ya mwenye mkataba wa bima, mtu wa kati
Management 2.3.2 Where a claim is serviced through an kushughulik na Kampuni ya bima.
intermediary, it shall be the duty of the intermediary to ia Madai 2.3.2 Endapo dai linashughulikiwa kupitia kwa mtu
provide the relevant claimant/beneficiary or claim wa kati, mtu wa kati atawajibika kumpa
progress feedback at least once every week by using mdai/mnufaika husika mrejesho wa maendeleo ya
a convenient means of communication including the dai/madai angalau mara moja kila wiki kwa kutumia

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SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA USHUGHULIKIAJI WA
INSURANCE CLAIMS MADAI YA BIMA
claimant’s registered mobile phone number and/or njia rahisi ya mawasiliano ikijumuisha nambari ya
email address until such date the claim is fully simu ya kiganjani iliyosajiliwa ya mdai na/au barua
executed. pepe hadi tarehe madai yatakapolipwa

2.4 Handling of 2.4.1 If in the course of claims settlement, a dispute 2.4 Ushughuliki 2.4.1 Iwapo wakati wa malipo ya madai patatokea
Claim arises between the claimant and the insurer on the aji wa mgogoro kati ya mdai na Kampuni ya bima juu ya
Disputes claims settlement amount, or coverage, staff Migogoro ya kiasi cha malipo ya madai, au wigo wa malipo,
handling claims disputes shall be those experienced Madai wafanyakazi wanaopaswa kutatua mgogoro husika
and appropriately qualified in claims handling. watakuwa ni wale wenye uzoefu na waliohitimu
2.4.2 Dispute resolution procedures shall follow a ipasavyo katika kushughulikia madai.
balanced and impartial approach, bearing in mind 2.4.2 Taratibu za utatuzi wa migogoro zitafuata
the legitimate interests of all parties involved. The njia ya uwiano na usio na upendeleo, kwa
procedures shall avoid being overly complicated, kuzingatia maslahi halali ya pande zote
such as having burdensome paperwork zinazohusika. Taratibu ziepushwe kuwa ngumu
requirements. kupita kiasi bila sababu ya msingi.
2.4.3 Insurers shall put in place mechanisms (such 2.4.3 Kampuni za bima zitaweka utaratibu (kama
as claims committee) for review of claims disputes vile kamati ya madai) kwa ajili ya mapitio ya
within the insurer to promote fair play and objectivity migogoro ya madai ndani ya kampuni ya bima ili
in the decisions. kuleta haki na usawa katika maamuzi.

2.5 Out sourcing 2.5.1 Where an insurer outsources any of the claims 2.5 Upatikanaji 2.5.1 Pale ambapo Kampuni ya bima inapata toka
of Claims handling processes in part or in full, the relevant wa Huduma nje huduma za uchakataji madai kwa sehemu au
function. insurer shall maintain close oversight and ultimate za kikamilifu, Kampuni ya bima husika itawajibika

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SECTION TWO: MINIMUM STANDARDS FOR PROCESSING OF SEHEMU YA PILI: VIWANGO VYA CHINI VYA USHUGHULIKIAJI WA
INSURANCE CLAIMS MADAI YA BIMA
responsibility for the provision of fair and transparent Kushughuliki kuweka uangalizi wa karibu wa utoaji wa haki na
claims handling and claims dispute resolution a Madai uwazi wa kushughulikia madai na utatuzi wa madai.
Kutoka Nje

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SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
3.1 Claim 3.1.1 In the event of a loss: 3.1 Utoaji 3.1.1 Tukio la hasara linapotokea:
Notification i. The policyholder or his representative may verbally Taarifa ya i. Mkatabima au mwakilishi wake atatoa taarifa kwa
notify the insurer within 48 hours; Madai kampuni ya bima kwa mdomo ndani ya saa 48;
ii. The policyholder or his representative shall notify
ii. Mkatabima au mwakilishi wake atatoa taarifa kwa
the insurer in writing (by letter, email or other means
kampuni ya bima kwa maandishi (kwa barua,
acceptable by the insurer) within seven (7) days;
barua pepe au njia nyingine inayokubalika na
iii. The notice shall specify the date and time, nature,
kampuni ya bima) ndani ya siku saba (7);
location and circumstances of the loss; and
iv. The policyholder shall give all such other information iii. Taarifa hiyo itaelezea; tarehe na muda, chanzo,
and take all such steps as the insurer may eneo na mazingira ya tukio la hasara;
reasonably require in relation to the loss.
iv. Mkatabima atapaswa kutoa taarifa nyingine
yoyote na kuchukua hatua zingine zote
zitakazohitajiwa na kampuni ya bima.

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SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
3.2 Acknowledg 3.2.1 Upon receipt of notification of loss from the 3.2 Kukiri 3.2.1 Baada ya kupokea taarifa ya hasara kutoka kwa
ment policyholder or his representative, the insurer shall take the kupokea mkatabima au mwakilishi wake, kampuni ya bima itachukua
following actions: Taarifa hatua zifuatazo:
i. Acknowledge in writing receipt of the written notification i. Kuthibitisha kupokea taarifa ya hasara kwa maandishi
within forty-eight (48) hours; ndani ya saa arobaini na nane (48);
ii. Avail an appropriate claim form and a list of specific ii. Kutoa fomu ya madai na orodha ya nyaraka
documents required when filing a claim within forty-eight zinazohitajika wakati wa kuwasilisha madai ndani ya saa
(48) hours of written notification; arobaini na nane (48);
iii. Provide any additional information that will assist in iii. Kutoa taarifa yoyote ya ziada ambayo itasaidia katika
dealing with the claim within time specified in 3.2.1 (ii); kushughulikia madai ndani ya saa arobaini na nane (48);
iv. The insurer shall endeavor to ensure that the policyholder iv. Inapohitajika, kampuni ya bima itawasiliana na kampuni
or his representative submits to the insurer the completed nyingine ya bima ambayo inahusika katika madai ndani
claim forms accompanied with relevant documents within ya saa sabini na mbili (72);
seven (7) days of receiving claim forms from the insurer; v. Ikihitajika, kampuni ya bima itateua mtoa huduma
v. Where applicable, the insurer shall contact any other aliyesajiliwa na Mamlaka ndani ya siku kumi na nne (14)
insurer that is involved in the claim within seventy-two (72) baada ya taarifa kutolewa; na
hours; vi. Kuchukua hatua nyingine zozote zitakazoharakisha
vi. The insurer shall appoint a service provider licensed by mchakato wa madai.
the Authority, if necessary, within fourteen (14) days; and 3.2.2 Ikiwa ajali itahusisha kifo au majeraha ya mwili,
vii. Undertake any other actions which will expedite the claim kampuni ya bima italazimika kutoa orodha ya nyaraka
processing. zinazotakiwa kwa mkatabima au mwakilishi wake kwa ajili ya
3.2.2 In case of a loss involving death or bodily injury the uhakiki wa madai ambayo itajumuisha vielelezo vifuatavyo:
insurer shall avail a checklist of all necessary required i. Nakala ya mchoro wa ajali;

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SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
documents to the policyholder or his representative for claim ii. Hati ya bima;
assessment which shall include: iii. Leseni ya udereva;
i. Accident sketch map; iv. Kadi ya umiliki wa gari;
ii. Cover note; v. Fomu za Polisi Na. 90, 93 & 115;
iii. Driver’s License vi. Fomu ya madai; na
iv. Registration card; vii. Kitamulisho/pasi ya kusafiria.
v. Police report PF 90, 93 & 115; 3.2.3 Aidha, Kampuni ya bima itapaswa kutoa orodha ya
vi. Claim Form; and nyaraka zinazotakiwa kwa mdai au mwakilishi wake kwa ajili
vii. Identification card/Passport. ya uhakiki wa madai ambayo itajumuisha vielelezo
3.2.3 In addition, the insurer shall provide a list of required vifuatavyo:
documents to the claimant or his representative for Kama ni majeraha:
verification of claim assessment. i. Fomu za Polisi Na. 90, 93 & 115;
In case of bodily injury: ii. Nakala ya hati ya mashitaka;
i. Police report PF 90, 93 & 115; iii. Nakala ya hukumu;
ii. Copy of charge sheet; iv. Taarifa ya mwisho ya daktari inayoonesha, pamoja
iii. Copy of judgement; na mambo mengine, asilimia ya ulemavu;
iv. Final medical report showing, among other things, v. Uthibitisho wa gharama za matibabu; na
percentage of incapacitation; vi. Uthibitisho wa kipato.
v. Proof of medical costs; and Kama ni kifo:
vi. Proof of income. i. Fomu za Polisi Na. 90, 93 & 115;
In case of death: ii. Nakala ya hati ya mashitaka;
i.Police report PF 90, 93 & 115; iii. Nakala ya hukumu;
ii.Copy of charge sheet;

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SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
iii.Copy of judgement; iv. Uthibitisho wa gharama za matibabu (kama
iv.Post-mortem report; inahusika);
v.Proof of medical costs (if applicable); v. Taarifa ya uchunguzi wa maiti;
vi.Death certificate; vi. Cheti cha kifo;
vii.Proof of funeral costs; vii. Uthibitisho wa gharama za mazishi;
viii.Proof of income; viii. Uthibitisho wa kipato;
ix.Proof of dependants; ix. Uthibitisho wa utegemezi;
x.Letter of identification of the deceased from Local x. Barua ya utambulisho wa marehemu kutoka serikali
Government Authority; and za mitaa; na
xi.Letters of administration of the deceased. xi. Uthibitisho wa uteuzi wa usimamizi wa mirathi.

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SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
3.3 Admissibility 3.3.1 Where a claim is admissible and can be settled 3.3 Kukubal 3.3.1 Pale ambapo madai yanakubaliwa na yanaweza
of Claims without any further assessment, the insurer shall issue a ika kwa kulipwa bila tathmini zaidi, kampuni ya bima itatoa hati ya
discharge voucher to the claimant within seven (7) days from madai kuridhia malipo kwa mdai ndani ya siku saba (7) kuanzia
the date of final submission of the documents from the tarehe ya kuwasilishwa kwa vielelezo kutoka kwa mdai.
claimant. 3.3.2 Pale ambapo dai halilipiki kampuni ya bima inapaswa
3.3.2 Where claim is not admissible the insurer shall notify kumtaarifu mdai ndani ya siku saba (7) na kueleza sababu za
the claimant in writing within seven (7) days and specify the kutokulipika kwa dai hilo kwa maandishi, kuanzia tarehe ya
reasons for the inadmissibility of the claim from the date of kuwasilishwa kwa vielelezo kutoka kwa mdai.
final submission of the documents from the claimant.

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SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
3.4 Appointment 3.4.1 Where the claim requires further assessment by an 3.4 Uteuzi 3.4.1 Endapo madai yatahitaji kufanyiwa tathmini zaidi
of service independent party to verify the claim and/ or quantify the loss, wa Mtoa na mtoa huduma anayejitegemea, ili kuthibitisha
provider the insurer shall appoint a service provider within forty-eight Huduma uwepo wa dai au thamani ya dai, kampuni ya
(48) hours from the time of receiving all documents from the bima itateua mtoa huduma ndani ya saa arobaini
claimant/his representative. na nane (48) tangu alipopokea vielelezo vyote
3.4.2 The appointed service provider shall provide kutoka kwa mdai/mwakilishi.
assessment report within thirty (30) days from the date of 3.4.2 Mtoa huduma ambaye atafanya tathmini atapaswa
appointment. kutoa ripoti ya tathmini ndani ya siku thelathini (30) kutoka
3.4.3 Where the insurer is dissatisfied with the assessment tarehe ya uteuzi;
report referred to under 3.4.2 and require to appoint another 3.4.3 Iwapo kampuni ya bima haijaridhika na ripoti ya
service provider, he shall in writing notify the Commissioner tathmini iliyotajwa kwenye 3.4.2 na itahitaji kuteua mtoa
and complete the assessment within a period of fourteen (14) huduma mwingine kufanya tathmini nyingine, itamtaarifu
days; Kamishna kwa maandishi na kukamilisha tathmini hiyo ndani
3.4.4 An insurer shall remunerate the service provider no ya muda usiozidi siku kumi na nne (14);
later than fourteen (14) days after receipt of the assessment 3.4.4 Kampuni ya bima italipa ujira wa mtoa huduma ndani
report from the service provider. For the avoidance of doubt, ya muda usiozidi siku kumi na nne (14) baada ya kupokea
the assessment report shall meet the conditions specified in ripoti ya tathmini kutoka kwa mtoa huduma. Kwa kuepusha
the relevant engagement contract. shaka, ripoti ya tathmini itatimiza masharti yaliyoainishwa
katika mkataba wa kutoa huduma husika.

13
SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
3.5 Issuance of 3.5.1 Upon receipt of the assessment report and 3.5 Kutolewa 3.5.1 Baada ya kupokea ripoti ya tathmini ya mtoa huduma
Discharge recommendations from the service provider: kwa Hati na mapendekezo yake:
Voucher i. Where the claim is admissible the insurer shall issue a ya i. Iwapo dai linalipika kampuni ya bima itatoa Hati ya
Discharge Voucher within seven (7) days from the date kuridhia malipo kwa mdai ndani ya siku saba (7) kutoka
Kuridhia
of receipt of the assessment report; and tarehe ya kupokea ripoti ya tathmini; na
Malipo
ii. Where the claim is not admissible the insurer shall notify ii. Iwapo dai halilipiki kampuni ya bima inapaswa
the claimant within seven (7) days and specify the kumtaarifu mdai ndani ya siku saba (7) na kutoa sababu
reasons in writing for the inadmissibility of the claim. za kutokulipika kwa dai hilo kwa maandishi.
3.6 Payment of 3.6.1 Where Discharge Voucher has been issued to the 3.6 Ulipaji wa 3.6.1 Iwapo hati ya kuridhia malipo imetolewa kwa mdai
the Claim claimant the insurer is obliged to ensure that the claimant has Madai Kampuni ya bima inawajibika kuhakikisha kwamba
signed the Discharge Voucher or declined the offer within imesainiwa au imekataliwa ndani ya siku saba (7)
seven (7) days. 3.6.2 Iwapo mdai amesaini hati ya kuridhia malipo, malipo
3.6.2 Where the claimant has signed the Discharge yatafanywa ndani ya siku arobaini na tano (45) kwa mujibu
Voucher, payment shall be effected within forty five (45) days wa Kifungu cha 131 cha Sheria ya Bima.
from date of signature in accordance with Sec 131 of the Act,. 3.6.3 Iwapo hati ya kuridhia malipo imetolewa na mdai
3.6.3 Where the Discharge Voucher has been issued and hajaridhika na kiwango cha malipo pendekezwa kampuni ya
the claimant has declined the offer, the insurer shall resort to bima itafanya majadiliano na mdai kuhusu uwezekano wa
negotiations with the claimant on a revised offer. kiwango kipya.
3.6.4 Where the negotiations in 3.6.3 have not succeeded, 3.6.4 Iwapo majadiliano yaliyotajwa kwenye 3.6.3
the insurer shall advise the claimant in writing on the hayajafanikiwa, kampuni ya bima itapaswa kumuelekeza
modalities for addressing his grievances. mdai kwa maandishi hatua za kufuata ili kupata suluhisho.

14
SECTION THREE: TIME LIMIT FOR VARIOUS STAGES OF CLAIM SEHEMU YA TATU: UKOMO WA MUDA WA HATUA MBALIMBALI ZA
PROCESSING KUSHUGHULIKIA MADAI
3.6.5 Subject to 3.6.4 the modalities for addressing 3.6.5 Kwa kuzingatia 3.6.4 hatua za kufuata ili kupata
grievances shall at minimum include those specified under suluhisho la madai yake zitajumuisha kwa uchache
2.4 in these Guidelines. yalioainishwa katika 2.4 ya Miongozo hii.

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SECTION FOUR: PROHIBITED PRACTICES SEHEMU YA NNE: MAKATAZO

4.1 Prohibited 4.1.1 No insurer or service provider shall 4.1 Makatazo 4.1.1 Kampuni ya bima au mtoa huduma
Practices unreasonably breach the time frames for processing of hataruhusiwa kukiuka ukomo wa muda wa
insurance claims specified in these Guidelines. kushughulikia madai ulioainishwa kwenye Miongozo
4.1.2 No insurer shall unreasonably repudiate or hii;
reject to settle a legitimate claim. 4.1.2 Kampuni ya bima haitaruhusiwa kukataa kulipa
4.1.3 Without prejudice to 4.1.1, no insurer or the madai halali ya bima;
service provider shall unreasonably lengthen claim 4.1.3 Bila kuathiri 4.1.1, kampuni ya bima au mtoa
assessment process; huduma hataruhusiwa kurefusha mchakato wa
4.1.4 An insurer or the service provider shall not kuthamini madai bila sababu ya msingi;
engage in unethical or unfair practices which prejudice 4.1.4 Kampuni ya bima au mtoa huduma
the rights of the insured or prospect or beneficiary or hatajihusisha na vitendo vinavyokiuka maadili au
other registrants. vinavyoathiri haki za mteja wa bima wa sasa au
4.1.5 Insurer and the service provider shall not mtarajiwa au mnufaika au watoa huduma wengine; na
engage in any other practice deemed by the 4.1.5 Kampuni ya bima au mtoa huduma
Commissioner of Insurance to be improper or prejudicial hatajihusisha na vitendo vingine vyovyote
to the rights of the insured or prospect or beneficiary or vitakavyohesabiwa na Kamishna wa Bima kuwa si
other registrants. sahihi au ni dhuluma kwa haki za mteja wa sasa au
mtarajiwa au mnufaika au watoa huduma wengine.

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 SECTION FIVE: SUPERVISION AND MONITORING SEHEMU YA TANO: USIMAMIZI NA UFUATILIAJI

5.1 Reporting 5.1.1 Reporting requirements 5.1 Utoaji wa 5.1.1 Mahitaji ya Utoaji wa taarifa
Requirements i. The insurer shall on a daily basis register Taarifa i. Kampuni ya bima, itapaswa kila siku
with the Authority each intimated claim and kuwasilisha kwa Mamlaka taarifa ya kila
update the Authority on the status of each dai lililotolewa taarifa na kuhuisha taarifa
registered claim through TIRA-MIS. za madai hayo kupitia TIRA-MIS.
ii. The insurer shall submit to the Authority, ii. Kampuni ya bima itawasilisha kwa
monthly reports on management of claims. Mamlaka, taarifa za kila mwezi za
iii. The reports required under item (ii) shall be ushughulikiaji wa madai.
submitted within seven days of end of the iii. Taarifa zinazohitajika kuwasilishwa chini
period referred thereto, using the forms in ya kipengele (ii) zitawasilishwa ndani ya
the manner and format to be prescribed by kipindi cha siku saba baada ya kuisha
the Authority. kwa muda uliotajwa, kwa kutumia fomu
iv. The insurer shall submit any other report na mfumo utakaowekwa na Mamlaka.
related to its claims management which iv. Kampuni ya Bima itawasilisha taarifa
the Authority may require from time to time. nyingine yoyote inayohusiana na
ushughulikiaji madai ambayo Mamlaka
itahitaji mara kwa mara.
5.2 Record 5.2.1 The insurer shall maintain a Claim 5.2 Utunzaji wa 5.2.1 Kampuni ya bima itapaswa kuwa na
Keeping Register for recording of data/ information relating to Kumbukum Rejista ya Madai kwa ajili ya kutunza kumbukumbu/
bu

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SECTION FIVE: SUPERVISION AND MONITORING SEHEMU YA TANO: USIMAMIZI NA UFUATILIAJI

insurance claims relating to its policyholders which taarifa zinazohusiana na madai ya bima
shall include: yanayohusiana na wakatabima ambayo itajumuisha:
i. Full names of policyholder/ claimant as shown i. Majina kamili ya mkatabima/mdai kama
in the National Identity card/Passport or other inavyoonyeshwa kwenye Kitambulisho cha
acceptable forms of identification; Taifa/Hati ya kusafiria au aina nyingine ya
ii. Date of inception of cover; utambulisho inayokubalika.;
iii. Physical Address; ii. Tarehe ya kuanza kwa mkataba wa bima;
iv. Class of business; iii. Anwani ya Makazi;
v. Sum insured for each covered risk; iv. Aina ya biashara;
vi. Premium charged; v. Thamani ya janga lililokatiwa bima;
vii. Amount of claim; vi. Ada ya bima iliyolipwa;
viii. Date of claim intimation; vii. Kiasi cha madai;
ix. Date of acknowledgement of claim notification/ viii. Tarehe ya kutolewa taarifa ya madai;
intimation; ix. Tarehe ya kukiri kupokea taarifa ya madai;
x. Date of submission by the claimant of the x. Tarehe ya kuwasilisha fomu ya madai iliyojazwa
completed claim form together with relevant kikamilifu pamoja na viambatisho vinavyohusika;
claim attachments; xi. Tarehe ya uteuzi wa mtoa huduma (kama
xi. Date of appointment of service provider (where inahitajika);
applicable); xii. Tarehe ya kutolewa kwa hati ya kuridhia malipo;
xii. Date of issuance of Discharge Voucher; xiii. Kiasi kinachopaswa kulipwa kulingana na hati ya
xiii. Amount Payable as per Discharge Voucher; kuridhia malipo;

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 SECTION FIVE: SUPERVISION AND MONITORING SEHEMU YA TANO: USIMAMIZI NA UFUATILIAJI

xiv. Date of Signing of the Discharge Voucher by xiv. Tarehe ya kusainiwa kwa hati ya kuridhia malipo
the Claimant; na mdai;
xv. Date of Settlement of the Claim; and xv. Tarehe ya Ulipaji wa Madai; na
xvi. Any other relevant information. xvii. Taarifa nyingine yoyote muhimu.
5.2.2 The insurer shall maintain actual records 5.2.2 Kampuni ya bima itapaswa kutunza
relating to each of the indicators specified kumbukumbu halisi zinazohusiana na kila moja ya
under 5.2.1. viashiria vilivyoainishwa katika 5.2.1.
5.2.3 The claim register of the insurer shall be kept 5.2.3 Rejista ya madai ya bima itawekwa katika
at the Head Office of the insurer and shall be Makao Mkuu ya Kampuni ya bima na itapatikana
available for inspection by the Authority. kwa ukaguzi wa Mamlaka.
5.2.4 The Authority shall specify the format and 5.2.4 Mamlaka itaainisha muundo na namna ya
manner of maintenance of records referred utunzaji kumbukumbu chini ya Miongozo hii.
to under these Guidelines.
5.3 Legal Any person who contravenes the provisions of 5.4 Utekelezaji Mtu yeyote atakayekiuka masharti ya Miongozo hii
Enforcement these Guidelines commits an offence and shall be wa Kisheria atakuwa ametenda kosa na atachukuliwa hatua na
subject to regulatory sanctions by the Kamishna wa Bima kwa mujibu wa Sheria ya Bima
Commissioner of Insurance as per the Insurance Sura Na. 394.
Act Cap 394.

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 SECTION SIX: REVIEW AND APPROVAL SEHEMU YA SITA: MAPITIO NA IDHINI
6.1 Review of 6.1.1 These Guidelines shall be reviewed once in 6.1 Mapitio ya 6.1.1 Miongozo hii itapitiwa kila baada ya miaka
the every three years for improvement. Miungozo mitatu kwa ajili ya maboresho.
Guidelines 6.1.2 Notwithstanding 6.1.1, the Commissioner may 6.1.2 Bila kuathiri 6.1.1, Kamishna anaweza kufanya
review these Guidelines as and when need arises. . mapitio ya Miongozo hii wakati wowote
itakapohitajika.
6.2 Effective These Guidelines shall come into force on the 1st 6.2 Tarehe Miongozo hii itaanza kutumika rasmi tarehe 1 Oktoba,
October, 2022. 2022.
date rasmi ya
kuanza
kutumika
6.3 Approval Approved by: 6.3 Idhini Imeidhinishwa na:

………………………………….
………………………………
Dkt. Baghayo A.Saqware
Dr. Baghayo A. Saqware
Kamishna wa Bima
Commissioner of Insurance

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