Insurance Claims Introduction, Need

Insurance is a legal agreement between two parties i.e. the insurance company (insurer) and the individual (insured). In this, the insurance company promises to make good the losses of the insured on happening of the insured contingency.

The contingency is the event which causes a loss. It can be the death of the policyholder or damage/destruction of the property. It’s called a contingency because there’s an uncertainty regarding happening of the event. The insured pays a premium in return for the promise made by the insurer.

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 non-life insurance industry is witnessing shifting trends across policy administration, and claims—the two core functions in insurance.

 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.

 In particular, insurers can transform the claims processing by leveraging modern claims systems that are integrated with robust business intelligence, document and content management systems. This will enhance claims processing efficiency and effectiveness. It can benefit the insurers both operationally and strategically by enabling them to reduce claims costs to improve their combined ratio, improve claims processing efficiency, and drive customer retention and acquisition.

 Today in any insurance office the claim process is built on

• Claim document & content management tool
• Mobile based & smart phone based technology solutions the key
• STP processing to minimize delay
• Modern claim processing platform which is seamless & robust

 Normal claim process followed by General Insurers

• An insured or the claimant shall give notice to the insurer of any loss arising under contract of insurance at the earliest or within such extended time as may be allowed by the insurer.
• On receipt of such a communication, a general insurer shall respond immediately and give clear indication to the insured on the procedures that he should follow. In cases where a surveyor has to be appointed for assessing a loss/ claim, it shall be so done within 72 hours of the receipt of intimation.
• Where the insured is unable to furnish all the particulars required by the surveyor or where the surveyor does not receive the full cooperation of the insured, the insurer or the surveyor as the case may be, shall inform in writing the insured about the delay that may result in the assessment of the claim.
• The surveyor shall be subjected to the code of conduct laid down by the Authority while assessing the loss, and shall communicate his findings to the insurer within 30 days of his appointment with a copy of the report being furnished to the insured, if he so desires. Where, in special circumstances of the case, either due to its special and complicated nature, the surveyor shall under intimation to the insured, seek an extension from the insurer for submission of his report.
• In no case shall a surveyor take more than six months from the date of his appointment to furnish On receipt of the survey report or the additional survey report, as the case may be, an insurer shall within a period of 30 days offer a settlement of the claim to the insured. If the insurer, for any reasons to be recorded in writing and communicated to the insured, decides to reject a claim under the policy, it shall do so within a period of 30 days from the receipt of the survey report or the additional survey report, as the case may be.
• Upon acceptance of an offer of settlement by the insured, the payment of the amount due shall be made within 7 days from the date of acceptance of the offer by the insured. In the cases of delay in the payment, the insurer shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by it.

How to Make a Claim under Motor insurance

A claim under a motor insurance policy could be

• For personal injury or property damage related to someone else. This person is called a third party in this context) or
• For damage to insured own vehicle. This is called an own damage claim and insured is eligible for this if he is holding what is known as a package or a comprehensive policy.

Third Party Claim

In a third party claim, where 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, insured is a victim, that is, if somebody else’s vehicle was involved, he must obtain the insurance details of that vehicle and make intimation to the insurer of that vehicle.

Own Damage Claim

In the event of an own damage claim, that is, where insured vehicle is damaged due to an accident, insured  must immediately inform insurance company and police, wherever required, to enable them to depute a surveyor to assess the loss.Insured must not attempt to move the vehicle from the accident spot without the permission of police and insurer.

Theft Claim

If P H 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 P H receives the policy document, he must read about the procedures and documentation requirements for claims.

If P H has to make a claim, he must ensure that he collects all the required documents and submit 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 in respect of a theft claim, there is a special requirement that P H 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 stationery – like a building, or moving around – like your household goods being transported.

P h 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 P H 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 be intimated to the relevant authorities such as the police, the fire brigade and so on. It is important to ensure that P H must intimate insurance company to enable it to send a surveyor for surveying and assessing the loss.

Travel insurance claim

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

P H can make a claim under a Health insurance policy in two ways:

1. Cashless basis and
2. Reimbursement basis

On a Cashless basis: For a claim on cashless basis, treatment must be only at a network hospital of the Third Party Administrator (TPA) who is servicing your policy. P h 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 claim process and not read it at the time claim arises.

Claims on reimbursement basis: P H must read the clause relating to claims in policy document as soon as he receives it to ensure that he understands the procedure and the documents required for making a claim on 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 keep ready documents such as claim form, discharge summary, prescriptions and bills that he should submit for a claim.

The insurer and the insured get a legal contract for the insurance, which is called the insurance policy. The insurance policy has details about the conditions and circumstances under which the insurance company will pay out the insurance amount to either the insured person or the nominees.

Insurance is a way of protecting yourself and your family from a financial loss. Generally, the premium for a big insurance cover is much lesser in terms of money paid. The insurance company takes this risk of providing a high cover for a small premium because very few insured people actually end up claiming the insurance. This is why you get insurance for a big amount at a low price.

Any individual or company can seek insurance from an insurance company, but the decision to provide insurance is at the discretion of the insurance company. The insurance company will evaluate the claim application to make a decision. Generally, insurance companies refuse to provide insurance to high-risk applicants.

Insurance Claim

How does insurance work?

The insurer and the insured get a legal contract for the insurance, which is called the insurance policy. The insurance policy has details about the conditions and circumstances under which the insurance company will pay out the insurance amount to either the insured person or the nominees.

Insurance is a way of protecting yourself and your family from a financial loss. Generally, the premium for a big insurance cover is much lesser in terms of money paid. The insurance company takes this risk of providing a high cover for a small premium because very few insured people actually end up claiming the insurance. This is why you get insurance for a big amount at a low price.

Any individual or company can seek insurance from an insurance company, but the decision to provide insurance is at the discretion of the insurance company. The insurance company will evaluate the claim application to make a decision. Generally, insurance companies refuse to provide insurance to high-risk applicants.

Tax benefits on insurance

Apart from the safety and security benefits of buying insurance, there are also the income tax benefits that you can avail.

• Life insurance premium of up to ₹1.5 lakh can be claimed as a tax-saving deduction under Section 80C
• Medical insurance premium of up to ₹25,000 for yourself and your family and ₹25,000 for your parents can be claimed as a tax-saving deduction under Section 80D