What Is an Insurance Claim?
An insurance claim is a formal request by a policyholder to an insurance company for coverage or compensation for a covered loss or policy event. The insurance company validates the claim (or denies the claim). If it is approved, the insurance company will issue payment to the insured or an approved interested party on behalf of the insured.
Types of Insurance Claims
Insurance Claims come in many forms. It depends on the Insured’s Policy Coverage and the nature of incident. Various types of Insurance Claims are listed below:
Health Insurance Claims
A Health Insurance Policy will pay for the hospitalisation expenses, surgery expenses, doctor’ charges and medicine expenses.
There are 2 ways Health Insurance Claims are settled:
Cashless Claim Settlement Process: In a Cashless Claim Settlement Process, the Insured gets hospitalised for treatment at a Network Hospital and shows the Mediclaim E-Card to the Insurance Department of the hospital. The Insurance Company then settles the bill directly with the Hospital.
Reimbursement Claims Settlement Process: in a Reimbursement Claim Process, the Insurance Company reimburses the Insured for the hospitalisation expenses after he submits the necessary documentation.
Having health insurance is important because:
It reduces medical costs, making health care more affordable and accessible.
It facilitates access to care, resulting in better health outcomes.
It protects you from unexpected, high medical costs.
It helps you avoid large medical bills that can cause financial hardship.
It safeguards your family and protects your savings.
Insuring early ensures long-term security.
What are the factors that affect Health
Insurance premium?
Ans. Age is a major factor that determines the
premium, the older you are the premium cost will
be higher because you are more prone to illnesses.
Previous medical history is another major factor
that determines the premium. If no prior medical
history
exists, premium will automatically be
lower. Claim free years can also be a factor in
determining the cost of the premium as it might
benefit you with certain percentage of discount.
This will automatically help you reduce your
premium.
- If you have a grievance:
The Consumer
Affairs Department of the Insurance
Regulatory and Development
Authority (IRDA) has
introduced the Integrated Grievance Management
System (IGMS) which is an online system for
registration and tracking of grievances.
You must
register your grievance first with the insurance
company and in case you are not satisfied with its
disposal by the company, you may escalate it to IRDA
through IGMS by accessing www.igms.irda.gov.in. In
case you are not able to access the insurer’s grievance
system directly, IGMS also provides you a gateway to
register your grievance with the insurer.
Apart from registering your grievance through IGMS
(i.e., web), you have several channels for grievance
registration-through
e-mail (complaints@irda.gov.in),
through letter (address your letter to Consumer
Affairs
Department, Insurance Regulatory and Development Authority, 3rd Floor, Parishram Bhavan, Basheerbagh,
Hyderabad:4) or simply call IRDA Call Centre at Toll Free 155255 through which IRDA shall, free of cost, register you complaints against insurance
companies as well as help track its status. The Call
Centre assists by filling up the complaints form on the
basis of the call. Wherever required, it will facilitate in
filing of complaints directly with the insurance
companies as the first port of call by giving information relating to the address, telephone number, website
details, contact number, e-mail id etc of the insurance
company. IRDA Call Centre offers a true alternative
channel for prospects and policyholders, with
comprehensive tele-functionalities, serving as a
12 hours x 6 days service platform from 8 AM to 8 PM,
Monday to Saturday in Hindi, English and various
Indian languages.
When a complaint is registered with IRDA, it facilitates
resolution by taking it up with the insurance company.
The company is given 15 days time to resolve the
complaint. If required, IRDA carries out investigations
and enquiries. Further, wherever applicable, IRDA
advises the complainant to approach the Insurance
Ombudsman in terms of the Redressal of Public
Grievances Rules, 1998.