Claim Assistance

Claim settlement is one of the most important services that an insurance company provides you. Insurance companies are bound to settle the claims promptly. Every product has a different claim process which you might go through. You must know the process of claim before initiating with it. Here, we attempt to help you provide the information on the claim process. This will tell you what information you need before you get in touch with your insurance company and what you can expect from the claim process.

Health Insurance Claim Process

On a Cashless Basis

Cashless hospitalization is a facility provided by the Insurance Company wherein the policy holder can get admitted and undergo the required treatment without paying directly for the medical expenditure. The eligible medical expense, thus incurred, shall be settled by the Insurance Company directly with the hospital. The Cashless claim facility can be obtained only at the hospital listed in the network of the Insurance Company.

Inform Your Insurer

Hospitalization happens under two circumstances - planned and emergency.

Planned: Once your doctor has recommended for the hospitalization, contact your insurer immediately and inform about the hospitalization.

Emergency: In case of emergency hospitalization, you must inform your insurer within 24 hours of hospitalization.

Admit in the Hospital

Get admitted to the hospital by showing your health ID card or policy number for identification purpose. Hospital will check your identity and fill up the Pre-Authorization Form with all the relevant details and send it to the insurer.

Documents to Send with the Pre-Authorization Form

• Policy Copy/ Health Card
• ID proof with address
• Investigation Test reports from Pathologist
• Medico Legal Certificate (MLC) - in accident cases

(Note: you may require to send additional documents depending on your insurer's requirement)

Confirmation of Insurer to Proceed with Services

Hospital will submit the pre-authorization form to the insurer. Insurer will review the documents and provide confirmation to the hospital to proceed with the cashless services. Normally, the TPA issues a letter of confirmation within 3-6 hours provided all relevant documents are submitted.

Hospital Sends Bill to Insurer During Discharge

Hospital sends the final bill to the insurer at the time of discharge.

Direct Payment

Once the bill is confirmed, insurer makes payment directly to the hospital.

Claims on Reimbursement Basis

In case of a reimbursement claim, the policy holder pays the expenses himself to the hospital and then claims for a reimbursement of those expenses from the Insurance Company by providing necessary documentation.

Get the Treatment Done

Avail the treatment as prescribed. Intimate your insurer in case the treatment is done outside the network hospital. In the meantime, you can proceed with your treatment and pay the bill. Get all your original documents and reports from the hospital.

Submit the Documents to Your Insurer

• Complete and signed Claim form with attending doctor's prescription
• First prescription of the present illness, for which treatment has been undergone in hospital/nursing home
• Medical advice for hospitalization
• Discharge summary of hospital
• Final bill of the hospital
• Medical fitness certificate
• All test reports supported by medical prescription (pre and post hospitalization)
• All vouchers/bills/receipts pertaining to the tests mentioned above
• All medicines purchased from outside the hospital at any point in time to be supported by original prescription

(Note: you may require to send additional documents depending on your insurer's requirement)

Claim Documents Review by Insurer

Your insurer will review the claim documents received and effect the payment within 7 days of receiving documents. If the treatment claimed is not covered under your plan, a rejection letter will be sent to you stating the reason for the same.

Life Insurance Claim Process

Death Claim

When a person with a life insurance policy - called a life assured - dies, claim intimation should be sent to the insurance company as early as possible. The assignee or nominee under the policy can do this, and so can any close relative or the agent who handles the policy.

Claim Intimation

The claimant must submit the written intimation to the insurer at the earliest to enable the insurance company to initiate the processing. The claim intimation should be supported with basic information such as policy number, name of the insured, date of death, cause of death, place of death, and name and contact of the claimant.

Documents to Be Submitted with Insurer

• Filled-up claim form
• Certificate of death issued by Local Authority
• Policy document
• Claimant's Identity and Residence Proof
• Medical Records at the time of death and past illnesses (Medical Attendant Certificate, Hospital treatment Certificate, Admission Notes, Discharge/Death Summary, and Test reports, etc.)
• Legal evidence of title, if the policy is not assigned or nominated
• Copy of Post Mortem
• Form of discharge executed and witnessed
• Copy of FIR / Panchnama Report / Police Inquest Report / Police Final Report, in case of unnatural death

(Note: Additional documents may be requested on a company and case to case basis)

Settlement of the Claim

As per the IRDA regulation, the insurer is required to settle the claim within 30 days of the receipt of all the documents. If the claim is accepted, payment is made to the nominee, and if the claim is rejected, the same is required to be communicated to the claimant stating the reasons. If the claim requires further investigation, the insurer has to complete its procedures within six months from receiving the written intimation of claim.

Maturity Claim

Maturity payment is the payment made by the insurer to the insured on the date of maturity. The amount payable at the time of maturity includes the sum assured and bonus/incentives, if any.

Maturity Claim / Discharge Form

The insurance company sends the blank discharge form at least 2-3 months in advance of the maturity date to the insured to fill in the various details. You must ensure that you receive the maturity claim / discharge form from your insurer.

Documentation

• Original Policy document
• ID proof
• Age proof if age is not already submitted
• Copy of claimant's Bank Passbook and Cancelled Cheque
• NEFT Details

Claim Settlement

The insurance company will pay the maturity amount to the insured through a payee cheque or through direct credit into the account.

Accidental Disability / Critical Illness Claim

Claim should be intimated to the insurer at the earliest. The claim intimation should be supported with information such as policy number, name of the insured, date and cause of death, place of death, and name and relationship of the claimant.

Documentation

• Critical Illness claim form
• Medical records (current and past) viz. hospital records, reports of diagnostic tests done
• Original Policy Document
• Claimant's Identity and Residence Proof

The insurer reviews the documents submitted by the insured and, on the basis of the same, accepts or rejects the claim.

Motor Insurance Claim Process

Third Party Claim

If your vehicle is insured and has a third party liability cover, the compensation sought by the third party for damages in case of an accident will be fully paid by your insurance company.

Report to the Police: Where your vehicle is involved, it is important to report the accident to the police and obtain the first information report quoting details such as the registration number of the vehicle, license number of the driver, and the names/contact details of witnesses, if any.

Inform your insurer: Intimate your insurer immediately along with the basic details of the policy, driver, and place of accident. If another vehicle is involved i.e. if you are a victim, you must obtain the insurance details of that vehicle and intimate your insurer about it.

Submit documents to your insurer:

• Claim form
• Policy copy
• Registration Certificate
• Driving License
• First Information Report

Theft Claim

If you have Comprehensive coverage on your insurance policy, you will be covered for a stolen car as well and eligible to get a claim for the theft of your car.

Lodge an FIR: You must report to the police and obtain the First Information Report.

Inform your insurer: If your vehicle is not found within 90 days, you need to obtain a Non-traceable report from the police and submit the same to your insurance company.

Submit claim form and other documents — fill the claim form giving information like policy number, vehicle details, date, time and description of the incident, along with:

• Registration certificate (RC) of the vehicle
• Driving license
• Policy copy
• FIR
• Final Non-traceable report by police
• All sets of keys
• Letter addressed to the RTO intimating theft

Claim Settlement: If you have taken a car loan to purchase your car, the insurer will settle the amount directly to the financier. The settlement amount is based on the Insured Declared Value (IDV), which might however differ based on usage and market value.

Own Damage Claim

Claim for damage to your own insured vehicle is called an own damage claim, and you are eligible for this if you are holding what is known as a package or comprehensive policy.

Inform insurer and police: Where your vehicle is damaged due to an accident, you must immediately inform the insurance company and police, wherever required, to enable them to depute a surveyor to assess the loss.

Send your vehicle to the garage: You should send your vehicle to the garage or authorized workshop where you can also report your claim. Your workshop or garage will prepare an estimated cost of repairs and liaise with the insurance company.

Surveyor Inspection Report: The surveyor will inspect the vehicle and submit the inspection documents to your insurance company, which will review them and, on the basis of the inspection, authorize the garage or workshop for repairs.

Payment of Expenses: If your policy provides for cashless service, the insurance company will pay the workshop directly. In case of reimbursement service, the approved claim amount will be intimated to the garage, and you will be paid by the insurer within 7 days of submission of final documents.

Reimbursement documents to be submitted:

• Copy of the Insurance certificate cum Policy Schedule
• Claim form
• Copy of Registration Certificate
• Copy of Driving License
• First Information Report
• Estimate of cost
• Final repair invoice and receipt / Satisfaction voucher for cashless payment

Travel Insurance Claim Process

Medical Expenses

To lodge a claim, you must inform your insurer on their helpline number providing the necessary details. Fill up the claim form with the necessary details, sign it, and submit it to your insurer along with the following documents:

• Doctor's report
• Original Admission/discharge card
• Original Bills/Receipts/Prescription
• Original X-ray reports/ Pathological/ Investigative reports
• Copy of passport/Visa with Entry and exit stamp
• Cancelled Cheque

(It is necessary to obtain the attending Physician's signature on the form)

Claim Settlement: The actual claim process happens once you return home to India. Your documents are reviewed by the insurer and you get your claim recovered.

Loss and Delay of Baggage

Intimate the airline about your loss, lodge the complaint, and obtain a PIR report from the airline authority. Also inform your insurance company immediately. Fill up and sign the Claim Form and submit it to your insurer along with:

• Copies of Baggage Tags/ Boarding Pass/ Tickets
• Copies of correspondence with the Airline authorities/others about loss of checked baggage
• Property Irregularity Report (obtained from Airline)
• Details of compensation received from Airlines/other authorities, if any
• PIR report (to be obtained from airline authority)

Trip Delay or Cancelled

If the delay in flight is more than 6 hours, you must inform the airline authorities and your insurer as well. Submit the duly filled and signed Claim form along with:

• Original Bills of purchases made/ Expenses incurred during the period of delay
• Copy of Ticket and Boarding Pass
• Confirmation from the airlines clearly mentioning the scheduled arrival time and the actual arrival time
• Copies of correspondence with the Airline authorities certifying the delay
• If the trip is cancelled or interrupted due to medical reasons, medical reports and doctor's statement
• If the trip is cancelled or interrupted due to employment reasons, a termination letter from the company
• If due to other insured events, a police report confirming the incident

Personal Liability

You must inform your insurer immediately, giving them full details of the incident. Make sure that you do not commit to any benefit/compensation or enter into any agreement with any party involved. Submit documents to the insurer:

• Full statement of the facts in writing
• Witness statements
• Any other documents relevant to the incident, including Summons, Legal Notice, etc.

Loss of Passport

Lodge a complaint with the local police and obtain a First Information Report. Contact the Indian Embassy, wherever necessary. Submit the below documents to your insurer to settle the claim:

• Copy of new passport
• Copy of previous passport (if available)
• Copy of return tickets
• Copy of First Information Report
• Details of expenses incurred in obtaining a fresh passport

Home Insurance Claim Process

Inform Your Insurer

You must inform your insurer immediately and provide relevant information, including your policy and other details regarding your claim. Your insurer authenticates your claim request and escalates it to the claim department.

Insurer Appoints Surveyor

If the claim department validates and registers your claim request, a surveyor is appointed within 48 hours. You will need to submit all relevant documents to the surveyor, who will inspect the incident and the nature and extent of loss, and make a report.

Submit the Documents to the Surveyor

The insured or the insured's legal representative is required to complete and sign the Claim Form, and along with it submit the below documents as proof of the event occurring and the nature and extent of loss:

• First Information Report
• Investigation Report by the Police
• Fire Brigade Report (in case of fire)
• Estimate of the repairers
• Invoice of the suppliers for replacement
• Court Summons
• Invoices of owned articles, if required
• Proof of rent in dwelling and dwelling taken up as alternative accommodation
• Carrier's Invoice
• Rent Agreement
• Proof to show withdrawal from Bank
• Transport details for baggage loss
• Copies of the duplicate securities and copies towards proof of expenses paid for recovery of duplicate certificates
• Medical Officer's Certificate for death or disability
• Hospital Bills for expenses for treatment
• Post Mortem Certificate, wherever required
• Legal opinion, wherever required

Claim Settlement

On receipt of all the documents, the insurance company processes the claim within 10-15 working days.

Frequently Asked Questions

Which are the necessary documents for the compensation of a claim?

List of necessary claim documents to be submitted for compensation are as follows:

• Claim form duly signed
• Hospital Discharge summary
• Copy of photo ID of patient
• Investigation reports
• Hospital Main Bill
• Operation Theatre notes
• Hospital Break up bill
• Original investigation reports, X-Ray, MRI, CT films, HPE, ECG
• Doctor's reference slip for investigation
• Pharmacy Bills

Are there any investigations that happen once the receipt of claim is done?

The Company may investigate claims at their own discretion to verify the validity of the claim. Such inquiry shall be concluded within 15 days from the date of assigning the claim for investigation and not later than 6 months from the date of receipt of the claim intimation. Verification carried out, if any, can be done by people or entities authorised for it.

Whom do I actually have to contact for claim intimation and settlement?

You must notify your insurer either at the call center or in writing, in the event of a planned or emergency hospitalisation.

Here we help you to guide through the various claim processes which you might go through with insurance companies. If in case you need further assistance, you may simply email us at [email protected]