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Claims

Management

MEDICLAIM
The following documents are
required:
Duly completed claim forms
Bills, receipts and discharge
card
from the hospital
Cash memos from the
hospital
Bills from chemists supported
by proper prescription
Surgeons bills and receipts,
bills from pathologist
supported by proper
prescription

GUIDELINES FOR
CLAIMS SETTLEMENT BY
IRDA

Except in cases of a marine insurance cover, where


current market practices do not insist on a written proposal
form, in all cases, a proposal for grant of a cover, either for
life business or for general business, must be evidenced by
a written document. It is the duty of an insurer to furnish
to the insured free of charge, within 30 days of the
acceptance of a proposal, a copy of the proposal form.
Forms and documents used in the grant of cover may,

depending
upon the circumstances of each case, be made available in
languages recognized under the Constitution of India.
In filling the form of proposal, the prospect is to be guided

by the
provisions of Section 45 of the Act. Any proposal form
seeking
information for grant of life cover may prominently state
therein
the requirements of Section 45 of the Act.

Where a proposal form is not used, the insurer shall


record the information obtained orally or in writing, and
confirm it within a period of 15 days thereof with the
proposer and incorporate the information in its cover
note or policy.
Wherever the benefit of nomination is available to
the proposer, in terms of the Act or the conditions of
policy, the insurer shall draw the attention of the
proposer to it and encourage the prospect to avail the
facility.
Proposals shall be processed by the insurer with
speed and efficiency and all decisions thereof shall be
communicated by it in writing within a reasonable
period not exceeding 15 days from receipt of proposals
by the insurer.

FACTORS AFFECTING
THE CLAIMS
MANAGEMENT

The policy should be in force on the date of the


event.
The risk and cause of event should be covered by
the policy.
The cause of loss or the event should be directly
related to the loss. A remote cause has no place in
the settlement.
The loss should not have been caused with an
intention to gain from the situation.

Sufficient documentary evidence of loss should be


presented along with the application form.
Multiple claims and reciprocal claims will be settled as
per the terms of the contract of insurance.
Presence of insurable interest, in case of the property
insurances, at least at the time of happening of event
or loss sufferings. Without having the insurable
interest in the subject matter, no person can get
benefit or compensation.

IMPORTANCE OF TIME
ELEMENT IN THE CLAIMS
PAYMENT

The delay in the claims settlement will have an adverse impact


on the goodwill and marketing of the insurance.
The cost of claims will increase with the extension of time
because the insurer may be asked to pay the interest on the
unpaid insurance amount because of the delay. The court may
direct the insurer to pay the costs of the case to the assured,
which results in mounting up of costs.
The delay in payment may lead to litigation which is expensive.
-Unproductive use of manpower to defend
-expenses incurred
-waste of time
-will affect on the productive areas of the business particularly
in the marketing of the insurance business.