RoleClassClaimant - HL7 Terminology (THO) v5.5.0

HL7 Terminology (THO)
5.5.0 - Publication International flag

This page is part of the HL7 Terminology (v5.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

ValueSet: RoleClassClaimant

Official URL: http://terminology.hl7.org/ValueSet/v3-RoleClassClaimant		Version: 3.0.0
Active as of 2014-03-26	Responsible: Health Level Seven International	Computable Name: RoleClassClaimant
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:oid:2.16.840.1.113883.1.11.20120
Copyright/Legal: This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license

Description: A role played by a party making a claim for coverage under a policy or program. A claimant must be either a person or organization, or a group of persons or organizations. A claimant is not a named insured or a program eligible.

Discussion: With respect to liability insurance such as property and casualty insurance, a claimant must file a claim requesting indemnification for a loss that the claimant considers covered under the policy of a named insured. The claims adjuster for the policy underwriter will review the claim to determine whether the loss meets the benefit coverage criteria under a policy, and base any indemnification or coverage payment on that review. If a third party is liable in whole or part for the loss, the underwriter may pursue third party liability recovery. A claimant may be involved in civil or criminal legal proceedings involving claims against a defendant party that is indemnified by an insurance policy or to protest the finding of a claims adjustor. With respect to life insurance, a beneficiary designated by a named insured becomes a claimant of the proceeds of coverage, as in the case of a life insurance policy. However, a claimant for coverage under life insurance is not necessarily a designated beneficiary.

Note: A claimant is not a named insured. However, a named insured may make a claim under a policy, e.g., an insured driver may make a claim for an injury under his or her comprehensive automobile insurance policy. Similarly, a program eligible may make a claim under program, e.g., an unemployed worker may claim benefits under an unemployment insurance program, but parties playing these covered party role classes are not, for purposes of this vocabulary and in an effort to clearly distinguish role classes, considered claimants.

In the case of a named insured making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that either a named insured or an individual insured has filed a claim for a loss. In the case of a program eligible, a role type code INJWKR (injured worker) subtypes the class to indicate that the covered party in a workers compensation program is an injured worker, and as such, has filed a “claim” under the program for benefits. Likewise, a covered role type code UNEMP (unemployed worker) subtypes the program eligible class to indicate that the covered party in an unemployment insurance program has filed a claim for unemployment benefits.

Example: A claimant under automobile policy that is not the named insured.

References

This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

Logical Definition (CLD)

Include codes from http://terminology.hl7.org/CodeSystem/v3-RoleClass where concept is-a CLAIM

Expansion

Expansion based on codesystem RoleClass v4.0.0 (CodeSystem)

This value set contains 1 concepts.

Code	System	Display	Definition
CLAIM	http://terminology.hl7.org/CodeSystem/v3-RoleClass	claimant	Description: A role played by a party making a claim for coverage under a policy or program. A claimant must be either a person or organization, or a group of persons or organizations. A claimant is not a named insured or a program eligible. Discussion: With respect to liability insurance such as property and casualty insurance, a claimant must file a claim requesting indemnification for a loss that the claimant considers covered under the policy of a named insured. The claims adjuster for the policy underwriter will review the claim to determine whether the loss meets the benefit coverage criteria under a policy, and base any indemnification or coverage payment on that review. If a third party is liable in whole or part for the loss, the underwriter may pursue third party liability recovery. A claimant may be involved in civil or criminal legal proceedings involving claims against a defendant party that is indemnified by an insurance policy or to protest the finding of a claims adjustor. With respect to life insurance, a beneficiary designated by a named insured becomes a claimant of the proceeds of coverage, as in the case of a life insurance policy. However, a claimant for coverage under life insurance is not necessarily a designated beneficiary. Note: A claimant is not a named insured. However, a named insured may make a claim under a policy, e.g., an insured driver may make a claim for an injury under his or her comprehensive automobile insurance policy. Similarly, a program eligible may make a claim under program, e.g., an unemployed worker may claim benefits under an unemployment insurance program, but parties playing these covered party role classes are not, for purposes of this vocabulary and in an effort to clearly distinguish role classes, considered claimants. In the case of a named insured making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that either a named insured or an individual insured has filed a claim for a loss. In the case of a program eligible, a role type code INJWKR (injured worker) subtypes the class to indicate that the covered party in a workers compensation program is an injured worker, and as such, has filed a "claim" under the program for benefits. Likewise, a covered role type code UNEMP (unemployed worker) subtypes the program eligible class to indicate that the covered party in an unemployment insurance program has filed a claim for unemployment benefits. Example: A claimant under automobile policy that is not the named insured.

Explanation of the columns that may appear on this page:

Level

A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies

System

The source of the definition of the code (when the value set draws in codes defined elsewhere)

Code

The code (used as the code in the resource instance)

Display

The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application

Definition

An explanation of the meaning of the concept

Comments

Additional notes about how to use the code

History

Date

Action

Author

Custodian

Comment

2023-11-14

revise