Page 278 - IC38 GENERAL INSURANCE

The above list is only indicative. Additional information/documents may be
required depending on specific case details or depending upon claim
settlement policy/procedure followed by particular insurer.

Test Yourself 5

________________ are paid upfront by Assistance Company and later claimed
from insurance company.

I. Bail bond cases
II. Personal accident claims
III. Overseas travel insurance claims
IV. Untenable claims

Summary

a) Insurance is a „promise‟ and the policy is a „witness‟ to that promise. The
occurrence of insured event leading to a claim under the policy is the true
test of that promise.

b) One of the key rating parameter in insurance is the claims paying ability of
the insurance company.

c) Customers, who buys insurance is the primary stakeholder as well as the
receiver of the claim.

d) In Cashless claim a network hospital provides the medical services based on
a pre-approval from the insurer / TPA and later submits the documents for
settlement of the claim.

e) In reimbursement claim, the customer pays the hospital from his own
resources and then files claim with Insurer / TPA for payment.

f) Claim intimation is the first instance of contact between the customer and
the claims team.

g) If a fraud is suspected by insurance company in case of insurance claim, it is
sent for investigation. Investigation of a claim could be done in-house by an
insurer/TPA or be entrusted to a professional investigation agency.

h) Reserving refers to the amount of provision made for all claims in the books
of the insurer based on the status of the claims.

i) In case of a denial, the customer has the option, apart from the
representation to the insurer, to approach the Insurance Ombudsman or the
consumer forums or even the legal authorities.

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