Purchasing an insurance policy is just the beginning. The true challenge of any insurance plan arises when you need to file a claim. For many, the claims process can seem perplexing, sluggish, and laden with paperwork. However, there is actually a straightforward system in place.
Let’s simplify how insurance claims are handled from beginning to end.
- Claim Intimation: Notifying the Insurance Company
The initial step involves informing the insurance company that a claim needs to be filed.
This process is known as claim intimation.
Depending on the insurance type, this can occur in various ways:
✔ For health insurance → hospital/network desk
✔ For motor insurance → surveyor or insurer helpline
✔ For life insurance → family informs the insurer after a death
✔ For travel insurance → customer service or app
Most insurance providers now offer intimation through:
apps
websites
toll-free numbers
claim desks at hospitals
- Document Submission: Demonstrating the Loss
Insurance relies on proof. To assess the claim, insurers require documents such as:
Health Insurance
admission papers
medical reports
bills & receipts
discharge summary
Motor Insurance
photos of the damage
repair estimates
FIR (in certain cases)
driving license copy
Life Insurance
death certificate
ID proofs
policy documents
claim form
The purpose of these documents is straightforward:
to confirm that the loss occurred and is covered by the policy.
- Verification & Investigation
After the insurer receives your documents, they will verify the details to ensure:
✔ the event took place
✔ the insured individual is the one affected
✔ the policy was active
✔ there were no exclusions or fraudulent activities
In health claims, they may check:
hospitalization details
treatment legitimacy
if pre-existing disease rules apply
In motor claims, a surveyor might physically inspect the vehicle damage.
In life insurance claims, insurers will confirm:
cause of death
policy duration
nominee details
Investigation becomes deeper only if:
- death happened early in the policy
- suspicious circumstances exist
- large claims are involved
- Adjudication: Decision Making
This is the stage where the insurer determines if the claim will be:
✔ approved
✔ partially approved
or
❌ rejected
The decision is based on:
policy terms
sum insured
exclusions
waiting periods
documentation clarity
correctness of claim
If the claim is approved, the insurer will calculate the final amount to be paid.
- Settlement: Paying Out the Claim
After approval, the payment can be made in various ways:
Health Insurance
Cashless: the insurer pays the hospital directly
Reimbursement: the customer pays upfront, and the insurer reimburses later
Life Insurance
money is disbursed to the nominee
Motor Insurance
paid to the repair garage or the vehicle owner
In India, the IRDAI has set timelines for claim settlements to safeguard customers.
- Rejection: When Claims Are Denied
Claims are often denied due to:
❌ policy exclusions
❌ non-disclosure of medical history
❌ pre-existing conditions without waiting
❌ expired policy
❌ fraud or misrepresentation
❌ incorrect documentation
This highlights the importance of understanding policy terms and providing accurate information.
Behind the Scenes: The Purpose of the Process
Insurance operates on the principle of pooled funds. If every claim were settled without any checks, the industry would be overwhelmed by fraud. Therefore, verification serves to safeguard both:
policyholders (stops increases in premiums)
insurers (avoids bankruptcy)
Cashless vs Reimbursement (Quick Difference)
| Feature | Cashless | Reimbursement |
|---|---|---|
| Payment | Insurer pays hospital | Customer pays, insurer refunds |
| Ease | Higher | Medium |
| Network required | Yes | No |
| Documents | Fewer | More |
Cashless is usually smoother if hospital is in the insurer’s network.
Tips to Avoid Claim Rejections
To improve claim success:
✔ Disclose accurate information
✔ Don’t hide medical history
✔ Understand waiting periods
✔ Read exclusions properly
✔ Pay premiums on time
✔ Keep documents organized
✔ Inform insurer early during emergencies
Final Thoughts
Claim processing may look complicated from outside, but it follows a logical pipeline:
Intimation → Documents → Verification → Decision → Settlement
The more transparent and timely the information, the smoother the claim.
Insurance exists to protect you during the worst moments of life — but protection works best when you understand how the system functions.
