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How To Avoid Hassles While Handling Insurance Claims?


Time to read: 3 mins | December 27, 2016

When it comes to Insurance, the one thing most individuals worry about is the lengthy, complicated claim settlement procedure. Many times the claims are rejected/delayed due to incomplete paper work.

So we decided to share a few pointers and the list of documents required to settle claims for life insurance and health insurance policies .

Here are some basic guidelines to help you in speedy recovery of claims. Of course, the procedure would differ from one insurance company to another. So, in order to avoid delays, please read the policy terms carefully.

1. In case of death claim (natural death or unnatural death)

The first step is to fill the Claim Intimation Form (CIF) of the respective insurer and attach the mandatory as well as supporting documents. These documents may vary from insurer to insurer, but the customer care centre or the support team, or your insurance agent can give you a precise list.

While filling up the Claim Intimation Form, please note…

  • Photograph of the 'claimant' must be affixed on the CIF along with signature/thumb impression across the photograph.
  • All the policy numbers of the deceased person need to be mentioned, enabling complete and smooth processing of claim(s).
  • The personal details of 'claimant', most importantly the address with pin code, telephone numbers, email id, and bank details; must be completely and correctly filled to enable timely correspondence.
  • The address mentioned in the CIF must match the valid address proof, because all correspondences will be sent to the 'claimant' on the address mentioned.
  • Ensure the bank details match the proof that's submitted.
  • Select the mode through which you'll like to receive the claim. Thus don't forget to signify the same in the CIF. It is a mandatory requirement to further process the claim pay-out.
  • The details of the 'insured' must be accurately filled. This gives an overview of the person insured at the proposal stage vis-à-vis at the time of claim.
  • Complete details of the claim event are very essential, as it provides a synopsis of the cause(s) that led to the claim.
  • Past history / habits give the 'insurer' an overview about the health / medical state of the 'insured'. Hence, do ensure that all details along with all relevant medical records, as supporting, are mentioned and annexed.
  • The details of all life insurance policies must be filled including other policies with the insurer. If the 'insured' had no other policies, mark it as Not Applicable (NA) or explicitly say, "No other policies".
  • Authorisation & Declaration should be completely filled by the 'claimant'. In the case if you as the 'claimant' are signing in a vernacular language or marking a thumb impression, all details of witness and scribe are to be duly filled to enable the 'insurer' to communicate all claim correspondence.

The documents required to be submitted for a death claim are…

Mandatory Documents Natural Death Unnatural Death
Duly filled Claim Intimation Form Required Required
Original policy documents Required Required
Original death certificate issued by the State / Municipality or an equivalent authority Required Required
Photograph of the 'claimant', his current address proof, and photo ID proof Required Required
Copy of bank's passbook/statement of the claimant bearing the IFSC code Required Required


Supporting Documents Natural Death Unnatural Death
Medical certificate stating the cause of death Required Not Required
Medical records (consultation notes, treatment records, admission notes, hospital indoor papers, discharge / death summary, investigation reports etc.) Required Required
Medical Questionnaire / Physician's Statement Required Not Required
Copy of duly certified First Information Report /Inquest / Panchnama (translation mandatory in case vernacular language) Not Required Required
Copy of duly certified Post Mortem Report / Chemical Analysis Report (Viscera) Not Required Required
Copy of Driving License if the Insured Person was driving the vehicle at the time of accident. Not Required Required
Settlement Option Form as applicable (lump sum or instalment as the case may be) Required Required

 

(Note: The table is indicative and not exhaustive)
(Source: PersonalFN Research)

Further…

  • All submitted documents must be in original and/or photocopies should attested by a gazetted officer, SEM, magistrate or a person of local standing e.g. Sarpanch, Talathi, Tahsildar, or Police Sub-Inspector.
  • All medical reports, documents, and certification shall be issued by the attending physician and who is qualified to provide such document/certification according to India legal code.
  • Depending on the facts and circumstances of the claim, the life Insurance company reserves the right to call for certain additional documents.
  • The life insurance company reserves the right to conduct an independent investigation/inquiry to prove the authenticity of any claim where it is considered necessary.

2. In case of health insurance claim

Make sure to intimate the 'insurer' at least 48 hours in advance in case of a planned surgery/treatment. You can email or call the customer service centre. Don't forget to make a note of the 'Claim Intimation Number' (CIN), as this is required to mention in all your future claim related correspondence with the insurer.

In the case of emergency hospitalization , do inform the insurer within 24 hours of admission.

Procedure for reimbursement of medical expenses:

  • Please send the duly signed 'claim form' and all the information/documents necessary to the 'insurer' within 15 days of the completion of the treatment. The documents to be submitted along with the said form are:
    • Copy of the intimation letter, if any
    • Hospital bill
    • Break-up of the hospital bill
    • Payment receipt of the hospital bill
    • Discharge Summary provided by the hospital
    • Pharmacy bills
    • Operation Theatre (OT) notes
    • ECG
    • Doctor's request for investigations
    • Investigation reports (including CT, MRI/USG/HPE, etc.)
    • Doctor's prescriptions
    • Cancelled cheque for NEFT
  • If there is any deficiency in the documents/information submitted by you, the 'insurer' will send the deficiency letter within 7 days of receiving of the claim documents.
  • Only when the complete set of claim documents are received by the 'insurer', payment shall be made for the admissible amount, along with a settlement statement within 30 days.
  • The payment will be made in the name of the 'proposer' i.e. the insured.
  • Payment will only be made for items covered under your policy and up to the limits therein.

Procedure to avail cashless facility:

  • For any emergency hospitalisation, the 'insurer' must be informed no later than 24 hours after hospitalization.
  • For any planned hospitalization , kindly seek cashless authorization from the 'insurer' at least 48 hours prior to the hospitalization.
  • The 'insurer' will check your coverage as per the eligibility and send an authorization letter.
  • If the documents sent are incomplete or incorrect, the hospital will be notified within 6 hours of receiving these documents. The documents to be submitted:
    • Claim Form properly filled in and signed by the 'claimant' along with medical certificate form filled, signed and stamped by the treating doctor
    • Original Discharge Card / Summary from the hospital / nursing home
    • Doctor's consultation reports / history
    • Hospitalization and other medical bills, receipts in original
    • Cash Memos from hospital / pharmacies supported by proper prescription
    • Investigation reports
    • Medico Legal Certificate (MLC) for accident cases
  • In case the ailment/treatment isn't covered under the policy, a rejection letter would be sent to the provider within 6 hours.
  • You ought to pay the non-medical expenses and expenses not covered by the policy to the hospital prior to being discharged.
  • The 'insured' is entitled for cashless claims only at hospitals empanelled by the 'insurer' (For the same, please refer to the list of empanelled hospitals on the insurer's website or the list provided in the welcome kit).
  • And please note, rejection of cashless claims in no way is rejection of the claim.

To conclude…

Although the checklists mentioned above are guidelines, following them would help you handle claims in a hassle-free way.

Keep your family members or your loved one in the know as to where you're storing insurance policies. This will help them handle the claim settlement procedure, in case of an untoward event(s). Remember involving your family while planning your personal finances, can ensure their long-term financial wellbeing.

CUSTOMER CORNER

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