¿Para qué sirve una empresa de gestión de siniestros?
Cuando los usuarios sufrimos accidentes y debemos cobrar la prestación del seguro (sea de una póliza del hogar, del vehículo, de la empresa, del comercio, etc), debemos cobrar de la aseguradora del culpable que nos ha causado el daño. En este caso, nos pueden suceder dos cosas:
- Que todo vaya sobre ruedas y cobremos lo que corresponda.
- Que el asunto se tuerza por alguna razón y surjan problemas a modo que cobremos menos de lo que toca, lo cobremos tarde, o simplemente nos rechacen pagar.
Puedo tener problemas con el seguro
Los problemas con las aseguradoras generalmente surgen por las siguientes razones:
- Porque la aseguradora interpreta las leyes y el contrato de manera inadecuada y sesgada a su favor, y por tanto, aparece una divergencia de criterios con el usuario en cuanto a su aplicación. O sea, la aseguradora busca algún argumento contractual para pagar menos o evitar pagar el siniestro. Y lo cierto es que el seguro puede tener razón, pero muchas veces no la tiene.
- La segunda razón de conflicto es que la aseguradora tasa de manera insuficiente el valor de los daños, pérdidas, perjuicios materiales, lesiones, lucro cesante u otros gastos. O sea, el perito del seguro, con o sin razón, valora menos de lo que vale el daño o perjuicio por las razones que sea, que en ocasiones son acertada y en otras no.
- En otras ocasiones y de manera deliberada, algunas aseguradoras dilatan la resolución del caso reteniendo el pago de la prestación con el ánimo de que el usuario, sea asegurado o perjudicado, desista en su reclamación por agotamiento.
- Otra de las causas de conflicto es que alguna aseguradora, contrariamente a lo que la Ley establece, aplica ilegítimamente al perjudicado, víctima de un accidente, las excepciones que corresponden a su cliente.
- En otras ocasiones algunas aseguradoras rechazan el pago de la prestación del accidente alegando cualquier circunstancia sin acreditar ni justificar su decisión.
- También existen casos donde algunas aseguradoras desestiman la reclamación de las víctimas lesionadas en accidentes de tráfico alegando argumentos poco consistentes o sin justificación acreditada.
- Existen bastantes casos donde hay poca diligencia en la resolución de tu accidente y te dejan totalmente desatendido, no resuelven tu problema y tardan una eternidad sin una causa que lo justifique.
- Puesto la cobertura o exclusión del pago de un accidente depende siempre del origen y determinación de las causas, circunstancias y consecuencias del siniestro, hay bastantes peritos que decretan cosas inverosímiles, y de ello puede resultar el rechazo del pago de la prestación. Controlar este aspecto es crucial para proteger los derechos del usuario.
- En otras ocasiones y siguiendo instrucciones concretas de alguna aseguradora, algunos talleres arreglan mal tu vehículo ocultando daños o haciendo chapuzas. También montan piezas no originales o de inferior calidad a las preexistentes con la única finalidad de ahorrase dinero.
- Finalmente y por un tema de ahorro de costes, algunas aseguradoras envían directamente a operarios Low-Cost para que actúen en tu vivienda, comunidad, comercio o empresa. En ocasiones este cómodo sistema para el usuario repercute en trabajos ejecutados con prisas, manifiesta desidia y poca profesionalidad, resultando un trabajo mal hecho y sin esmero.
¿Cómo evito o resuelvo los problemas con el seguro?
Y ¿qué debe hacer un usuario para evitar padecer o resolver cualquiera de estos escenarios?
Existen tres escenarios y un servicio complementario:
- La prevención: En primer escenario es, una vez acaecido el accidente, cuando el usuario se “vacuna” para prevenir los problemas con la aseguradora. Y para prevenir los problemas, el usuario debe notificar el siniestro a una empresa de Gestión de Siniestros para que actúe antes que el seguro. La empresa de Gestión de Siniestros actuará, y en el momento que ella crea conveniente, declarará el accidente al asegurador para que pague la prestación. De este modo el usuario tendrá la certeza de la cobertura o rechazo de su caso antes de declarar el siniestro al seguro, y una vez declarado al asegurador, éste tendrá toda la documentación para poder realizar el pago. Es posible que el asegurador quiera enviar a sus peritos, donde no habrá ningún problema puesto siempre se obrará con total transparencia. En caso de surgir algún problema, éste se resolverá con plenas garantías. Es obvio que el trabajo del gestor debe retribuirlo el asegurado. En ClaimCenter denominamos este servicio como “Asesoramiento del accidente”.
- La corrección: El segundo escenario es que, por desconocimiento o porque el usuario quiere ahorrase el coste del Gestor de Siniestros, decide declarar el accidente a la aseguradora para que sea ésta quien gestione su caso. Si todo va sobre ruedas, el usuario cobrará lo que le corresponde y se habrá ahorrado el coste del Gestor de Siniestros. Pero dado el caso que surja alguno de los problemas antes enunciados, el usuario deberá “curar” el problema y acudir a un Gestor de Siniestros si quiere cobrar lo que en derecho le corresponde. En muchos casos los usuarios acuden a un abogado, desconociendo que en muchísimas ocasiones no precisan de abogados sino de otros profesionales. Pero el asunto está en que, si el usuario quiere “sanar la enfermedad” y cobrar lo que le corresponde, deberá contratar a un Gestor de Siniestros si no quiere tener muchos problemas y quebraderos de cabeza. En ClaimCenter denominamos este servicio como “Defensor del Asegurado”.
- La rendición: El tercer escenario sucede cuando el usuario tira la toalla y deja que la aseguradora se quede con lo que en derecho le corresponde. Para estos casos sólo tenemos la recomendación de que el usuario luche por lo que en derecho le pertenece, y si desea hacer caridad, la haga para quien realmente la necesita.
Y para finalizar tenemos los servicios complementarios que son los peritos de seguros, los cuales serán estrictamente necesarios para la reclamación del caso. Y de peritos de seguros existen de muchos tipos y especialidades, y por poner unos ejemplos te enunciamos algunos:
- Peritos de autos
- Peritos del hogar
- Peritos de empresas
- Peritos médicos
- Peritos de responsabilidad civil
- Peritos de responsabilidad profesional
- Peritos de lucro cesante
- Peritos reconstructores de accidentes de tráfico
- Peritos investigadores de incendios
- Comisarios de averías
Por tanto, la gestión de siniestros implica un alto grado de especialización en cuanto a técnica, conocimientos legales, de procedimiento y de organización operativa.
Y la conclusión está en que lo puede hacer uno mismo o darlo a una empresa especializada, dependiendo de la capacidad que uno tenga en invertir tiempo, dinero y paciencia.
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Buenos días,
tengo una humedad en el comedor y la aseguradora de la comunidad de propietarios dice que proviene de los vecinos y la aseguradora del vecino de donde podría venir la humedad dice que es de la comunidad.
¿Ustedes podrían hacerse cargo del peritaje y la reclamación?
Gracias y un saludo,
Adolfo.
Hola, cuando os encontráis con esta controversia debéis actuar del siguiente modo:
En primer lugar, la comunidad de propietarios debe encargar a un albañil experto para que encuentre el origen de la humedad.
Una vez localizado y acreditado el origen de los daños, será el «propietario de la causa», comunidad o particular, quien deberá hacerse cargo de todo; que es la localización y la reparación tanto de la causa como de todos los daños causados a terceros.
Si resulta que hay algún seguro que cubre total o parcialmente esos daños lo pagará. Si no, será el responsable quien deba hacerse cargo íntegro del coste.
Una vez acreditada la causa y reparada, si nadie se hace cargo de tus daños hay dos posibilidades:
La primera es que tu seguro te pague los daños por cobertura directa de daños propios y luego recobre al culpable.
La segunda es que, haciendo uso de la garantía de protección jurídica, tu seguro pague a peritos y abogados para plantear la reclamación de tus daños al culpable del accidente por vía amistosa o judicial.