Economic Times, October 25, 2009

It’s a common scenario in most homes. An insurance agent comes along, convinces you of how good the policy will be for you and after a couple of Choosing right insurance Reviving lapsed insurance policy How to go for householder’s insurance Thumb rules of buying an insurance Check the price before buying an insurance questions on sum insured and exclusions, hands over the forms. You put in your basic details, sign at the end of the form and the agent assures you that he will fill the rest of it up.

After a long day at work, you’re perhaps relieved that you don’t have to go through all the paperwork and relax in the assurance that you have provided for the needs of your family. End of story.

The issues, however, begin to arise, when you go to the company with a claim and they repudiate it on the basis of discrepancies or ask you for further documentation to support your claim. To give you the upper hand in such a situation, SundayET tells you what documents you require while filing a claim for the most common life and health insurance policies, while pointing out reasons why claims may be rejected by insurance companies.

Cracking the code

If the insured person passes away, the first step is to approach the insurance company with an intimation of the person’s death as well as the death certificate of the individual. Remember to keep policy documents as well as the address and identity proof of the nominee in your custody.

“However, in rare cases where a nominee isn’t mentioned in the form, then a succession certificate favouring the person who claims to be the legal heir needs to be furnished,” reminds Amarjeet Singh, assistant project director at CUTS Center for Consumer Action, Research and Training. If there are multiple legal heirs, then you would also need a relinquishment certificate on the part of the other heirs, giving up their rights to the claim.

Once you fill up the claim form given out by the insurance companies, the branch office sends it to the head-office where the claim liability will be recorded and can be settled within a fortnight in most cases. Serious investigation on the part of the companies generally takes place when the death occurs three to six months after the policy was taken and when the sum assured is very large.

The most common reasons for the repudiation of claims in life insurance is the discrepancies between the details declared on the form that you filled up initially and the actual medical condition of the person and even the cause of death. In fact, individuals do not disclose existing ailments like hypertension (blood pressure related problems) and diabetes for the fear of having to pay a higher premium or because the agent hasn’t declared it on the form, which could be an issue at the time of settlement.

Moreover, if investigations yield that the cause of death was suicide or had criminal overtones, and then the claim may be repudiated. However, insurance experts say that in a large number of cases, the claim is not rejected but delayed due to the lack of documents such as the relationship or nomination certificate and are settled once all the documents are in place.

Keeping it cashless

With regard to health insurance/ mediclaim policies, most offer cashless hospitalisation facility in a select group of hospitals. However, you will still need to intimate the insurance company of the admission in advance, to keep the process smooth and cash-free. “If hospitalisation is warranted due to an emergency, the patient will be admitted to any network hospital provided they have the Member ID card. Intimation to the company, however, must be made within 24 hours of admission to the hospital,” says Shreeraj Despande, head of health insurance at Bajaj Allianz General Insurance.

In case you are in a hospital that is not covered under your scheme and want to be reimbursed by your mediclaim policy, then you would need to contact the company within 14 days from the time that the patient is discharged..

illness from the time it was detected, including medical history and doctor’s consultation reports, diagnosis and the surgeon’s certificate stating the nature of the operation performed,” says Sanjay Datta, head, customer service-health and accidents at ICICI Lombard General Insurance.

Make it an absolute priority at every stage to keep all the bills, receipts and cash memos from the hospital, showing the break-up of expenses and records of money spent on diagnostic tests and charges by a consultant or a specialist, who may have been called specifically to attend on you.

Also check to see if your mediclaim policy covers pre and post hospitalisation expenses and the time frame for which this can be availed. “If you want the amount to be reimbursed, then you need to send all bills (in original) with supporting documents along with a copy of the discharge summary and a copy of the authorisation letter to your third party administrator (TPA). The bills must be sent to the TPA within seven days from the date of completion of treatment,” says Datta.

Experts say the typical reasons for rejection of a claim in such policies are the fact that the policy may not cover pre-existing diseases for the first few years. Moreover, each policy has a set of exclusions, both specific and permanent, which may vary from company to company.

In addition, for the first 30 days after you buy the policy, no claims, except those for accidents, are admissible. Another common issue for rejection is when claims are delayed or when the company feels that there may have misrepresentation of facts, especially with regard to treatment that may have been taken abroad.

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