You paid your premium on time. You kept your policy active. And so when you wanted to make a claim under your insurance, you expected the claim process to be smooth. But instead, you might have heard:
“Your claim is rejected…”
…or “Your claim is still under process…”
…or even the insurer has settled for a lower amount than you expected.
Sometimes the problem can be that you don’t know what is the issue with your insurance claim, or what to do about it.
Let us discuss some of the insurance claim problems faced by policyholders.
1. Insurance Claim Rejection
One of the most frustrating situations that a policyholder can face is when their claim is rejected.
Claims can be rejected for a variety of reasons:
• Policy exclusions
• Waiting periods
• Missing/incomplete documents
• Non-disclosure or incorrect information
• Coverage limitations
• Policy conditions
• Investigation findings
If your claim has been rejected, it’s important to not stop at the word “rejected”. You should read the rejection letter carefully, and look at the exact reason mentioned by the insurer and the relevant policy clause. You should also read our detailed guide on what to do if your insurance claim is rejected to understand the next steps.
2. Insurance Claim Delay
Your claim might not have been outright rejected, but that doesn’t always mean that everything is fine.
A claim might be pending for days or even weeks, with the policyholder left in uncertainty.
There can be a number of reasons for this:
• Additional documents
• Verification
• Investigation
• Assessment
• Incomplete information
• Internal processing
If your claim is delayed, make sure to keep in touch with the insurer and ask:
• What is exactly pending?
• What documents/information is needed?
• What is the current status of the claim?
Also, make sure to keep such communications in writing, if possible. If the issue continues, you can read more about insurance claim delay assistance provided by ECS.
3. Claim Settled for Less Than Expected
Another situation that can arise is a short or partial settlement.
Sometimes, a policyholder might expect one amount under their claim, but the insurer offers considerably less.
Before jumping to conclusions, always make sure to get the calculation from the insurer.
Check whether the difference is related to:
• Deductibles
• Co-payment
• Sub-limits
• Depreciation
• Exclusions
• Non-payable expenses
• Coverage limits
4. Repeated Requests for Documents
This is without doubt one of the most frustrating situations to be in.
You submit your documents. Then, an email comes in asking for more documents. You submit those. Then, yet another request comes in. If this is the case, make sure to keep a simple document tracker:
Document → Date submitted → Method → Acknowledgement
This will help you keep track of what has already been submitted.
5. Dispute About Policy Terms
Sometimes, the issue isn’t with the documents, but rather with the terms and conditions.
A policyholder might believe that their claim is covered under the policy, while the insurer might take the view that an exclusion, condition or limitation applies.
In such a situation, it’s important to not rely just on verbal discussions. Always make sure to read the actual policy wording..
6. Pre-Existing Disease or Disclosure Dispute
Health and life insurance claims can sometimes be subject to disputes over pre-existing disease or disclosure.
If the insurer takes the view that:
• There was a pre-existing disease
• Previous treatment was not disclosed
• The medical history was misrepresented
• There was non-disclosure
• There was incorrect declaration
…make sure to check your original proposal form and your supporting documents.
7. The Insurer Is Not Responding Properly
Sometimes, you might find yourself trying and trying to contact the insurer, but not getting a proper response.
You might not know:
• Whether the claim is registered or not
• What documents are pending
• Why the claim is delayed
• What the decision on the claim is
• What your next steps are
Always make sure to keep all communication and responses in case something goes wrong. If the situation doesn’t improve, policyholders can use the applicable grievance mechanism. IRDAI advises policyholders to first raise their complaint with the insurer; Bima Bharosa provides a route to register and track grievances.
Bima Bharosa – IRDAI Grievance Portal
What Should You Do If You Face an Insurance Claim Problem?
Use this simple flow:
Step 1: Identify the problem
Is it rejection, delay, short settlement, documentation or a coverage dispute?
Step 2: Collect your documents
Keep your:
• Policy
• Proposal form
• Claim form
• Bills
• Medical records
• Rejection/settlement letter
• Communication with insurer
Step 3: Ask for a written explanation
Don’t rely on phone conversations.
Step 4: Review the policy
Look at the actual terms and conditions.
Step 5: Use the appropriate grievance route
If the issue remains unresolved, explore the grievance mechanism at the insurer’s side, and also the applicable external mechanisms.
The Insurance Ombudsman is another avenue for grievance redressal for eligible matters, under the applicable rules.
Council for Insurance Ombudsman
Final Takeaway
An insurance claim problem can be many things – from rejection, to delay, to short settlement, to documentation issues or even a dispute over policy terms. The first thing to establish is what exactly has gone wrong.
If your insurance claim has been rejected, delayed, short-settled or is stuck with the insurer, don’t keep guessing what to do next.
Eternity Claim Solutions can help you review the issue, organisation the documentation and navigate the available grievance process.
Facing an insurance claim problem? Get FREE claim review by experts from Eternity Claim Solutions.
