Reporting claims

Claim - the very term sounds ambiguous and to many it gives jitters. The moment talk of 'insurance' crops up, the issue of 'claim' follows. We start questioning - whether I will get my lawful claim or will I be denied it on some pretext or the other. Read on to know how simple or complex the life insurance claim process is.

As soon as a claim happens, the claims division of the insurance company is to verify the covered loss, ensure fair and prompt payment of claims and provide assistance to the insured.

Broadly, your claim has to pass through the following steps - claim reporting, receipt of claims by the company, claim files and procedures, claims assessment and complaints and dispute settlement.

For claim reporting, the insurance company sends an appropriate claim form (when the loss reporting is made in writing) to the claimant (policyholder/ beneficiary). This also outlines the terms of the policy and legitimate requirements. But remember that all claims payable by an insurance company are subject to the production of proof of the claim event.

Intimation of the claim event through claim form, signed by the claimant (beneficiary/ nominee/ assignee/ legal heir) should mention the following - a statement that the claim event (death/ accidental death/ permanent disability/ critical illness) has occurred, details of the policy under which the insured is covered, date of the claim event, place of occurrence of the claim event (hospital/ residence, etc) and the address of such place and cause of the claim event, with supporting documents, etc. (or any other information asked for).

Acknowledging receipt of the claim form, if the claim cannot be settled quickly, the insurance company would provide an indicative time to the claimant. In case the claim is not covered by the insurance policy, the company sends a notification as soon as possible to the claimant, explaining why it is not covered.

If it is considered for the claim, then as a next step, the insurance company creates a claim file with indicative information such as claim filing number, policy number, name of the policyholder/claimant/beneficiary, summary sheet showing development / review of the claim, type of insurance concerned, opening date of the file, date of loss and reporting date, etc.

The company keeps updating the claimant on the status of his claim. It also assesses the damage and communicates this through a written estimate. The insurer sends a copy of the document used to set the amount of compensation to the claimant.

The final payment or offer of settlement is made with the explanation of purpose of payment/ settlement and basis used for payment/ settlement. In case of denial, the insurance company states explicitly to the claimant the reasons for denial of claim or in case it offers an amount different from the amount claimed.

If the claimant is not satisfied with the given explanation, the claimant can appeal to the dispute settlement procedures available outside the company (for example, the handling of complaints by the supervisory authorities) or can go to Irda ( Insurance Regulatory Development Authority) and click on Insurance Ombudsman to file the complaint.

The writer is vice president, www.apnapaisa.com