How to effectively present claims to an insurer

Published in Economic Times on 29 June, 2015, Written by Kapil Mehta

Over the years I have seen countless claims rejected because the case was ineffectively presented or process not followed. For example, an employee covered under group medical insurance did not intimate the Insurer/TPA about hospitalization at the time of admission into the hospital. He informed the insurer forty five days after discharge from the hospitalization. Since the insurance had a fifteen day intimation period the claim was rejected. In another case the insured claimed for an MRI without linking the MRI to any hospitalization. That claim, too, was rejected. These issues also crop up in fire and marine insurance

Here are some tips to effectively present claims:

Understand the insurer’s standard operating procedure

For example in group medical insurance there are two different kinds of claims:
Cashless -Cashless claim is the service in which you are not required to pay the hospitalization bills to the hospitals at the time of admission or discharge in the hospital. You need to get an authorization from the insurer for such facility at the time of hospitalization.
Reimbursement -When insured pays the hospitalization bills and recovers the money later. You need to collect all the original bill documents & reports at the time of discharge before initiating the claim process.

Understand your policy thoroughly

The foremost requirement while filing a claim is to understand the conditions and exclusions of your insurance policy. The next step is make sure the damage is being covered and to check if there is a procedure you need to follow and then take the decision of filing the claim. If the amount of the claim is small, think whether it is worth making a claim request. You may lose your no claim bonus for a small amount of claim. If you have bought the policy through a broker or agent, it’s better to talk to them first before you reach out to the insurer. This can speed up your claim settlement.

Document the damage and claim process

In case of accidents or medical treatment, keep all the documents, reports and bills handy. When filing claims for travel insurance, make a list of stolen items, note down the flight number, date and time of journey. In case of physical damage, take photographs and videos of damaged items as soon as the event occurs.
Note down the time and dates whenever you talk to the insurance company regarding claims. Keep a written record of the conversation with the insurer or TPA.

Follow the timelines

Most policies have time limits to report damages to the insurer. Before initiating the claim process, it’s better to call the insurer’s helpline number or email. Make a checklist of tasks and documents to furnish before initiating the claim.

Give the details clearly

To have a speedy claim settlement, make sure you fully explain the circumstances of the event. Make sure you have the policy document, receipts. If you have a police report keep that handy. Stick to the facts and do not exaggerate. Give the information asked for. Not more not less.
Insurers are not looking for ways to repudiate claims. However, they have limited time to spend on any one case. A well-presented claim where process has been properly followed is more likely to be approved than a case where the insurer has to dig deep to get basic facts.

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