Insurance Claim Services

How to lodge a claim

• Take immediate measures to extinguish fire and minimise loss
• Call for fire brigade assistance and lodge an FIR with the nearest police station
• Intimate the broker/insurer about the fire, and provide policy numbers and description of the property affected, and other details such as date and time of fire, location, estimated amount of loss, contact person details
• Retain the salvage till a surveyor inspects the loss, and act as per his advice

List of documents to be submitted in case of a claim

• Duly completed claim form
• Detailed note on incidence of fire
• Take photos/videos of the fire fighting/loss minimisation measures
• Certified copy of FIR, police panchnama
• Fire brigade report and their bill and receipt
• Newspaper cuttings, if a report appeared in the news paper
• Weather report, if loss is due to flooding/inundation
• Details of stock or plant and machinery or electrical installations and other properties
• Detailed statement of damages with their respective valuations as per policy conditions
• Details of salvage materials
• Estimate for repairs or replacements
• Purchase and sales register copies or details
• Audited Balance Sheet / Profit & Loss Account, Trading Account for the last three years
• Provisional Balance Sheet / Profit & Loss Account, Trading Account for the current year upto date of fire or loss
• IT & VAT Returns for preceding year, PAN card copy, and AAT Regn copy
• In case of Agreed Bank Clause, monthly stock statement to be submitted to the bankers for the financial year

Basically there are two types of process in Health Claims – Cashless claims & Reimbursement claims.

Cashless Claims

• For claim on cashless basis, the insured should get admitted to network hospitals of Third Party Administrator (TPA)/Insurance Company.
• The pre-authorisation form along with necessary documents like investigation report, previous consultation paper (if any),Cashless ID, Photo ID proof, residence proof etc. will be mailed by the hospital to the TPA/Insurance Company.
• The TPA will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
• TPA will settle the claim as per policy terms and conditions with the hospital after completion of necessary formalities.

Reimbursement claims

• For claim on reimbursement basis, the insured should get admitted to any Network/Non Network hospital. The claim should be intimated to the TPA/Insurance Company to get the claim number within stipulated time as per the policy terms and conditions.
• After getting discharged from the hospital, the insured should collect all the original documents from the hospital and submit the same to the TPA/Insurance Company along with the claim form and policy copy within stipulated time as per the policy terms and conditions.
• The TPA/ Insurance Company will review the claim request and accordingly approve, query or reject the same as per the policy terms and conditions.
• For approved cases, Settlement letter is mailed/couriered to the insured/proposer and Payment is released through NEFT/RTGS by the insurance company.
• For queried cases, query letter is sent to the client requesting for additional documents/information. Reminders are sent to the client and if the requested documents are not received after reminders, the claim closure letter is sent to the insured.
• For rejected cases, rejection letter is sent to the insured mentioning sufficient reasons as per the terms and conditions of the policy.

Documents for Claim

• Copy of the policy
• Copy of the Intimation Letter / Mail / Intimation No
• Duly filled & signed claim form
• Original discharge card / Discharge Summary duly signed by treating doctor and with hospital stamp.
• Original hospital bill with break-up details with serial no. duly sealed & signed.
• Original pre-numbered hospital payment receipt duly sealed & signed,
• Original prescriptions,
• Original pharmacy bills (please make sure patient name is mentioned on the bill)
• Original advance paid receipt if any
• Original investigation reports along with original bills & payment receipts for the investigations done within & outside hospitals.
• Original consultation papers, if any
• All Imaging Films, ECG Strips, Doppler / Angiogram CD etc.
• Hospital Registration Certificate (in case of a unknown small hospital)
• Any other original documents related to the claim.
• MLC/FIR in case of Accident cases.
• The copy of the cancelled cheque of the policy holder / Employee in case of corporate client where in claim is payable to employee
• If employee has availed a cashless but if the same is not utilized letter from the hospital mentioning the same.
• Copy of Valid Photo Id Proof of the patient & Policy holder / Employee in case of corporate client.
• Address Proof of Policy holder / Employee in case of corporate client if the claim is more than 1 lakh.

How to lodge a claim

• Immediate intimation to the insurance company or survey agents mentioned in the insurance policy / certificate
• Do not give a clean receipt when goods are received in unsound condition
• Give a notice in writing to the carrier or other bailees within three days, if loss or damage was not apparent at the time of accepting delivery
• Call for joint survey by carrier and / or other bailees representatives
• Take photographs of the consignment including damaged goods or packing
• Segregate sound goods from the damaged goods to prevent further aggravation of damage
• In case of road transport, obtain original certificate of facts from the carrier
• Cooperate with the surveyors in providing required documents and information on salvage process etc.
• Act as prudent uninsured

There are three types of claims for personal accident: Death, Permanent & Partial Disablement, Temporary disablement claims.

• In case of any accidental claim, intimate the claim to the insurer in writing or give a call at the toll free number of the policy giving full details of the claim. A claim number will be generated.
• Depending on the nature of the claim, documents are to be submitted to the insurance company for processing.
• On receipt of documents, the claims scrutiny is done by the insurer as per policy coverage.
• For approved cases, settlement letter is mailed/couriered to the insured/proposer and payment is released through NEFT/RTGS by the insurance company.
• For queried cases, query letter is sent to the client requesting for additional documents/information. Reminders are sent to the client and if the requested documents are not received after reminders, the claim closure letter is sent to the insured.
• For rejected cases, rejection letter is sent to the insured mentioning sufficient reasons as per the terms and conditions of the policy.

Documents for Claim
The following is an indicative list of documents required for processing a claim:

Death Claim

• Policy copy
• Claim form
• Attending doctor’s report with Medico Legal Certificate (MLC)
• Original death certificate
• Original / attested post mortem / coroner’s report
• Attested copy of FIR /Panchnama
• Police Inquest Report, where applicable

Disablement Claims

• Policy copy
• Claim form
• Attending doctor’s report with Medico Legal Certificate (MLC)
• Original disability certificate from the doctor
• Investigation / laboratory reports and other medical case papers
• Original discharge summary if hospitalised
• Attested copy of FIR /Panchnama
• Police Inquest report, where applicable
• In case of permanent total disability, disability certificate from competent authority

Weekly Benefit Claims
Policy copy

• Claim form
• Attending doctors report with Medico Legal Certificate (MLC)
• Attested copy of FIR /Panchnama
• Original disability certificate from the doctor
• Investigation / laboratory reports and other medical case papers
• Employee leave certificate with grade / designation from the HR of the company.

There are mainly three types of vehicle claims: Accident claims, Theft claims and Third party claims.

Cashless Claim
In case of damage to the vehicle

• Take the vehicle to the Cashless garage for repairs as far as possible. They will register the claim.
• Surveyor deputed by the insurance company will inspect the vehicle at the garage. The garage will give estimate of repairs to the surveyor. The claim form duly completed with Driving Licence, R.C. book, policy copy and any other documents called for by the surveyor will have to be shown to him. If the insured has to bear any amount which is not admissible, the same will have to be paid by him to the workshop. The surveyor will give approval after assessment. The garage will start the repair of the vehicle.
• After completion of repair vehicle will be handed over to the insured.

Reimbursement Claim
If the vehicle is to be repaired in a garage outside the purview of the network, then you can claim reimbursement for the same. Here the claim is to be intimated to the insurance company in writing or through toll free number. Claim form duly filled along with estimate for repairs have to be submitted to them for appointment of surveyor. Documents will be common for both cashless and reimbursement claim.

For Accident Claims

• In case of damage to the insured vehicle is due to accident, the vehicle registration number and the contact details of the third party/driver involved in the accident should be noted.
• Name of the witness and contact details should be noted
• Contact the toll free number OR mail to the insurance company giving full details of the accident and get the claim number.
• Submit claim documents to the insurance company like Duly signed claim form, RC copy of the vehicle, Driving licence copy, Policy copy, Original Estimate, FIR (case to case),Original repair invoice and Payment receipt (In case of cashless garage, the garage will follow the procedure)

For Theft Claims

• Register an FIR and then Immediately contact the toll free number or intimate the same in writing to the insurance company giving full details of the theft and get the claim number.
• In addition to the above mentioned documents required for accident claims, additional documents like RTO transfer papers duly signed along with Form 28, 29, 30 & 35 (if hypothecated), Final report from the police( if the vehicle is untraceable), RTO letter is required.

For Third party Claims
Immediately contact the toll free number of the insurance company giving full details of the accident and get the claim number. Lodge an FIR with the Police. All notices/summons received should be handed over the insurance company for defence.