Stuck Claims Recovery, Ombudsman Settlement, Consumer Forum / Court Settlement
Before buying, renewing, or porting an insurance policy, the most basic aspect one needs to check, among many other things, is how the insurer settles claims. The claim settlement track record of a general or a health insurance company gives an idea of how many claims it pays out during a financial year as a percentage of the total number of claims it gets.
An insurance claim is a formal request to an insurance company asking for a payment based on the terms of the insurance policy. The insurance company reviews the claim for its validity and then pays out to the insured or requesting party (on behalf of the insured) once approved.
The claims process is the defining moment in a non-life insurance customer relationship. To retain and grow market share and improve customer acquisition and retention rates, insurers are focused on enhancing customers’ claims experience. In a highly competitive insurance market, differentiation through new and more effective claims management practices is one of the most important and effective ways to maintain market share and profitability.
Today all General Insurance companies have a built-in CLAIM PROCESS system
- Simplified Claim documentation
- Content management tool
- Smart phone-based technology solutions
- Third-Party / In House dedicated claim processing team to minimize delay
- Modern claim processing platform which is seamless & robust
Motor insurance Claim
Third-Party Claim
In a third-party claim, where an insured vehicle is involved, it is important to ensure that the accident is reported immediately to the police as well as to the insurance company. On the other hand, the insured is a victim, that is, if somebody else’s vehicle was involved, he must obtain the insurance details of that vehicle and make an intimation to the insurer of that vehicle.
Own Damage Claim
In the event of an own damage claim, that is, where the insured vehicle is damaged due to an accident, the insured must immediately inform the insurance company and police, wherever required, to enable them to depute a surveyor to assess the loss. The insured must not attempt to move the vehicle from the accident spot without the permission of the police and the insurer. Theft Claim
If the holder’s own vehicle is stolen, he must inform the police and the insurance company immediately. In addition, you must keep the transport department also informed. As soon as the Policy Holder receives the policy document, he must read about the procedures and documentation requirements for claims.
If the holder has to make a claim, he must ensure that he collects all the required documents and submits them along with the requisite claim form duly filled in, to the insurance company. There may be certain specific documentation requirements for specific types of claims. For instance, with respect to a theft claim, there is a special requirement that the policyholder should surrender the vehicle keys to the insurance company.
Property insurance claim
There could be several types of policies that cover property and the property itself could be stationary – like a building, or moving around – like your household goods being transported.
Policy Holder on receipt of policy document must familiarize himself with the documents required for a claim as well as the procedures to be followed. Whether or not a claim arises Policy Holder must follow the various dos and don’ts in respect of his property for the duration of the policy. These dos and don’ts are termed warranties and conditions in the policy document. In general, losses and damages, including those due to theft, fire, and flood need to be intimated to the relevant authorities such as the police, the fire brigade, and so on. It is important to ensure that the Policy Holder informs the insurance company to enable it to send a surveyor to survey and assess the loss.
Travel insurance claim
A travel insurance policy is generally a package policy that includes different types of covers like hospitalization, personal accident, loss/ damage to baggage, loss of passport and so on.
The procedure and documents required for a claim would vary from cover to cover.
For ease of procedure and convenience, insurers normally attach the claim form with the policy document. This will contain the list of documents required in case of a claim and also the contact details including phone numbers of the claims administrator either in the destination country to which you are traveling or in another country that is designated to receive and process your claim intimation.
Formalities for a health insurance claim
Policy Holder can make a claim under a Health insurance policy in two ways:
- Cashless basis and
- Reimbursement basis
Claim on a Cashless basis: For a claim on a cashless basis, treatment must be only at a network hospital of the Third Party Administrator (TPA) who is servicing your policy. Policy Holder must seek authorization for availing the treatment on a cashless basis as per procedures laid down and in the prescribed form. He must read the policy document as soon as he receives it, to understand the claim process and not read it at the time the claim arises.
Claims on a Reimbursement basis: Policy Holder must read the clause relating to claims in the policy document as soon as he receives it to ensure that he understands the procedure and the documents required for making a claim on a reimbursement basis. When a claim arises he should inform the insurance company as per procedures required. After hospitalization, he has to ensure that he obtains and keeps ready documents such as claim forms, discharge summaries, prescriptions, and bills that he should submit for a claim.
When is a General Insurance claim rejected by the insurer?
It is very crucial to collate all the required documents before filing a claim. If your claim has been rejected once due to improper documentation, you can file it again with all proper documents. In general, there are 4 main reasons why a claim got stuck. They are Reason 1 – If your claim is found to be non-genuine
Reason 2 – Inability to produce the required documents
Reason 3 – Delay in filing the claim
Reason 4 – Non-renewal of insurance policy
But denial of the claim is not the end of the road. If your claim is either not entertained or is denied, you can approach the insurer and even the IRDAI. Claims rejection, delays in settling claims, and lack of proper communication with the policyholder are very common. Documentation is the most important thing in insurance, whether it is buying a policy or making a claim. After you file a claim and provide the company with all the documents it asks for, they should accept or reject the claim in two weeks. If this TAT is not adhered to, you can complain to the grievances officer by quoting the details of the policy and the claim.
Complaints to the grievance officer can be about dissatisfaction with the insurer, distribution channels, intermediaries, insurance intermediaries, or other regulated entities about an action or lack of action about the standard of service or deficiency of services. It is mandatory for all insurance companies to resolve a grievance within two weeks of its receipt.
If any complaint is not resolved, or resolved to your dissatisfaction, you can escalate your complaint to IRDAI which will take it up with the insurance company and facilitate a re-examination of the complaint and resolution.
If the company does not respond even after 15 days or if you are not satisfied with the action taken, you can escalate the complaint to the Insurance Ombudsman or seek other legal remedies if the insurance company’s response is not to your satisfaction.
All the above procedures require a professional approach and thorough knowledge on the subject, otherwise, your complaint will not be entertained by the higher officials. In case you need proper guidance we can help you to get your legitimate claim.
