How to make a claim for insurance

Claiming insurance compensation can sometimes claim your peace of mind. The territory is agog with complaints like that of Mumbai-based jeweller Rohit Bajaj, 36. His insurer did not pay him to get his car back on the road after an accident. But, then, the fault was his: he had not followed the correct procedure for making the claim. The lesson from his case is that we should never give the insurer an excuse to refuse a rightful claim.

Remember, an insurance company is not a charity. Profligacy can make it go belly up. So, it scrutinises every claim before making the payment. Since you have agreed to the insurer's terms, you should stick to them and not provide it an escape route when you make a claim. It is not enough to buy the right covers, you should also know what to do in case something goes wrong and the need for making a claim arises. To save money, effort, time and, most important, headaches, always do the following:

• Ask your agent what the claim procedure is, or, at least, read the policy document and get him to explain what you cannot understand.
•  Keep the insurer's toll-free number in your mobile phone or wallet so that you can call it when the need arises.
• Keep a copy of all the documents, bills and letters you send to the insurance company.

Apart from these steps, which apply to all kinds of insurance, measures specific to different kinds of cover need to be taken.

Health Insurance

It is broadly of two types: the standard mediclaim and the critical illness cover.

Mediclaim: It reimburses hospitalisation and surgery bills after you have spent the money. In a cashless policy, the insurer takes care of the bills through a third-party administrator (TPA) if you undergo treatment in an empanelled hospital. These policies cover surgeries for hernia, piles, sinusitis and gall bladder stones only from the second year; knee replacement surgery, prolapsed disc and joint replacement surgery are covered from the third year. The following is the procedure for cashless mediclaim:

• First send the duly filled pre-authorisation form more than a week before a planned surgery and keep track of it by being in touch with the TPA.
• ln case of accidents, the doctor has to fill in fields such as the time of accident and evidence of alcohol abuse. TPAs will have no option but to return incomplete or illegible forms to the hospital asking for clarifications, and that will delay the process.
• If you are accompanying the patient, mention your cell phone number in the pre-authorisation request. This will enable the TPA to get in touch with you.
• If your company gives you a cashless settlement card, keep it with you as it can be a great help in times of emergency.
• Check which of the network hospitals are nearest to your home or workplace. This will come in handy in an emergency.

Critical illness: This cover is paid on the diagnosis of an illness in the list and often takes care of hefty treatment costs.  Kartik Jain, head (marketing and E Channel), ICICI Lombard, says a policyholder must know whether the claim is payable on diagnosis or after the survival period, which is usually 30 days after diagnosis. If the person dies in this period, the claim will not be honoured. Some private insurers like ICICI Lombard pay on diagnosis of critical illnesses.

• Clarify with your agent which illnesses are covered before buying a policy.
• Call the toll-free number of the insurance company and ask for guidance.
• Keep all bills and photocopy them.

Personal Accident cover

This insurance is usually bundled with life cover policies for a small premium or given free with credit cards. Some general insurance companies also give personal accident covers on a yearly basis. Kausal Mishra, senior vice-president, Tata AIG General Insurance, says in most instances family members of persons who have personal accident cover are unaware of it. In such cases, there is chance that the policy may go unclaimed if the policyholder dies in an accident.

If an accident leads to the death of the policyholder, it is essential to intimate the insurance company at the earliest. Here are the steps you need to take:

• Submit the First Information Report (FIR) and the policyholder's death certificate.
• Retain a copy of the documents sent to the insurance company.
• If the accident results in an injury, the insurance company needs to be intimated about it soon. It will seek an explanation if there is a long gap between the time of the accident and when it is informed about it.
• Most insurers expect an intimation within seven days of the accident.
• They also expect a copy of the FIR of the accident.
• Submit medical certificate in case of partial or full disability and hospital bills.
• Follow up your case with the insurance company a fortnight after sending all the relevant documents to it. If efforts to get a response from it draw a blank for a month, send a letter to the insurance ombudsman.

Car Insurance

It is mandatory for a car owner to have at least third-party cover, but it is advisable to have full car insurance. There are three cases when there can be a claim.

Road accident: The bulk of the claims come under this head. S. S. Gopala Rathnam, president (operations), Cholamandalam MS General Insurance Company, says customers are more aware about claims procedures for motor insurance than other insurances.

If your car hits another vehicle:

• Inform the insurer immediately.
• Get the FIR from the traffic police.
• If the car is movable, take it to the nearest garage of your preference.
• If you have cashless insurance, you don't need to pay a penny to the garage.
• If another vehicle hits your car:
• Give the registration number of the vehicle that has hit your car to the insurance company.
• File an FIR if you or your co-passengers are seriously injured.
• If your car gets stolen:
• Report the theft to the neighbourhood police station.
• Inform the insurance company.
• Get a 'Non-traceable Certificate' from the police station after 30 to 60 days if the police cannot find your car.
• The insurer will process your claim only after getting this certificate.
• If your car is hit by a catastrophe:
• Call the insurer's toll-free number to register your claim and look out for special teams sent by it.

Travel Insurance

This cover is compulsory for those travelling to the US. Antony Jacob, managing director, Royal Sundaram, says that the travel insurance claims procedures are generally quite simple and are mentioned in the policy document. However, people face problems if they do not carry the policy details, helpline numbers and other  necessary information with them during travel. They also face problems when they are not aware of the claims procedure

• In case of hospitalisation, inform the Third Party Administrator (TPA) at the time of admission or immediately after admission to the hospital. If you want to go for cashless transactions, ask the TPA for it quoting the details of your policy.
• Whether you opt for the cashless mode or not, the TPA will need proof of travel documents and medical payments made.
• The attending physician will need to fill the medical form. Get this faxed to the TPA along with the requisite medical record.
• Report the loss of passport or visa to the police within 24 hours of becoming aware of the loss. A police report will be required for making claims.
• If baggage is lost, the following will have to be furnished: boarding pass and baggage coupons of the insured person, list of articles lost and their value if they are valued over $100, and proof of ownership.

Home Insurance

This covers all the valuables in your home. Like in the case of other covers, often policyholders don't know how to claim compensation under this insurance. Here's how to go about it:

• Call the insurer's call centre or your agent immediately when the need for a claim arises. Keep their phone numbers in your emergency list.
• Report burglaries to the police. Keep the purchase receipts of your jewellery carefully since the insurance company will verify whether you owned it before handing you the compensation.
• In case of rainwater flooding, take photographs of the damage before cleaning up and salvaging what is left.
• If a fire destroys your policy document too along with other belongings, inform the insurance company about it.
• Don't discard damaged material, as it will be required as proof of loss.
• After the insurance company's surveyor examines and estimates the loss, send a letter to the insurance company stating all the damages in detail. Keep a copy of this letter.