Insurance Claims Procedures: Understanding the Insurance Claims Process

More often than not, understanding how to claim insurance can be challenging, especially if an individual is unaware of what their policies cover or if they have provided sufficient information to claim it.

Knowing what to do in instances like when diagnosed with a critical illness would alleviate the anxiety and stress from experiencing such a traumatic event while ensuring that the claims are processed quickly and efficiently.

What is an insurance claim?

When an individual experiences a sudden or unexpected event that costs them money, they go through a loss. If an individual has insurance, they can get their insurance company to reimburse this loss.

Essentially, an insurance claim is a request by an individual for their insurance company to pay for an aspect or incident covered by the insurance, like admission to a hospital.

Types of insurance claims

Various circumstances could affect our lives, health, and medical status. As a result, incidents that fall under any of these four avenues are often eligible for insurance claims.

Life insurance claims
An individual with a life insurance policy usually lists one beneficiary or more, which can be a close relative, charity, or business, that can claim the money upon their death.

The beneficiary should submit a claim form, death certificate, and the original policy to the insurance agent or company to access the insurance. The process may require an in-depth examination to ensure that the death of the individual insured did not fall under a contract exclusion, like a suicide or death as a result of a criminal act. Life insurance payouts generally take around 30 to 60 days in non-extenuating circumstances.

Health insurance claims
Surgical procedures and inpatient hospital stays are costly proceedings. Individual or group health insurance policies help patients cover these costs instead of suffering financial damages by paying out of their pockets.

Providers of policyholders are able to file health insurance claims, which requires minimal effort since they are mainly determined electronically. Health insurance claim can protect an individual from suffering the consequences of an extensive financial burden from an illness or accident. It covers the fees of hospitalisation, ambulance, room and board, critical illnesses, maternity coverage, and more.

Medical insurance claim
Medical insurance is similar to health insurance, but its expenses are limited. For example, under medical insurance, only the expenses for hospitalisation are covered, with the policyholder being hospitalised for a minimum of 24 hours. In addition, it covers the cost of treatment for pre-specified illnesses and accidents for a limited amount.

Life insurance claims procedure

Filing a life insurance claim can lift the financial stress that comes about from the loss of a loved one. The following describes the process of filing for a life insurance claim.

Have all required documents in order

1. Provide a certified death certificate: With the certified proof of death, insurance agents and companies will be able to identify that the policyholder has indeed passed on, avoiding the possibility of the insurance being claimed under fraudulent circumstances. A death certificate copy can be requested from a funeral home, the medical professional who determined the time and place of death, or the local vital records office.
2. Policy document: The policy document contains information about the life insurance policy, including the policy number, the death benefit amount, and beneficiary names. Contact the insurance company or the deceased’s financial advisor if there is trouble locating the policy document.
3. Claim form: This is a form where the details about the policyholder, like the policy number and cause of death, are filled out. The beneficiary would also need to indicate the relationship to the policyholder and list the method of payment to claim the insurance.

Contact insurance company
Upon collecting all the required documents, contact the insurance agent or company that issues the life insurance policy to inform them of the death of the individual and file a claim as the beneficiary.

Your claim will be reviewed
Upon filing the claim, the insurance agent or company will check to ensure that the policy is active and confirm the beneficiary filing for the claim matches the policy document.

A life insurance claim can be claimed at any point upon a loved one’s passing as long as their policy was active prior to death. The sooner a claim is filed, the quicker the beneficiary receives the payment. The life insurance may be reimbursed within a few days but can take as long as 60 days. Claims may be denied if the policy coverage has expired, been terminated, or has not been paid for.

Receive death benefit
A beneficiary receives insurance through a lump sum or annuity based on the life insurance company and plan. With a lump sum, the entire insurance is given to the beneficiary at once, and there is no need to pay taxes on it. On the other hand, an annuity is an account where the insurance is invested and paid back via an annual instalment plan, and taxes are paid based on investment gains.

Health/Medical insurance claims procedure

The following describes the procedure to claim health and medical insurance.

Contact your insurance provider
Before receiving any non-emergency treatments, an individual should contact their insurance provider to clarify any misunderstandings about the insurance claim and to understand what is covered by the policy.

Prepare required documents
The required documents tend to vary based on the insurance policy and company, so it is important to confirm the necessary documents beforehand. Generally, the documents needed include:

• A photocopy of an individual’s NRIC/passport

• Original hospital receipts and invoices

• Itemised hospital bills or detailed bills

• Diagnostic reports, like blood tests, coronary angiograms, and X-rays

• Copies of passport, boarding pass, flight ticket details, and an original itemised bill (This is only needed by individuals wanting to claim their insurance for medical treatment overseas)

Complete claim forms
Obtain the claim forms from the insurance company or download a copy from the insurer’s website. If the policy requires a Medical Examiner’s Statement, an individual must seek a doctor to fill up that section.

Check documents and make copies
Check and ensure that all the documents are filled and in order. Making copies before submitting the claim can be handy for reference if there are any complications with the claim.

Submit your claim
An individual can submit a claim via an insurance agent or insurance branch. They can check the status of a claim by contacting the agent, contacting the insurance customer service line, or emailing the insurer.

Other tips for insurance claims

• Ensure that claim forms and other required documents are completed correctly and accurately to avoid any unnecessary delays.

• Make sure that the signature on the claim form is the same as the one on the insurance records.

• A doctor’s statement is meant to be completed at the claimant’s own expense.

• Insurance companies reserve the right to request any other relevant documents and information which may not have been mentioned above.

• The insurance company may request to view the original copy of documents that have been submitted whenever they deem it necessary.

How quickly are insurance claims paid out?

Insurance claims are usually paid out within 14 to 60 days. However, the investigative period can be extended if there is a valid reason to do so, which would result in the insurance claim being paid out much later.

Insurance claim settlement
An insurance claim settlement refers to the payment that an insurance company offers to an individual as a response to them filing a claim. The settlement lists the final amount that has been paid to the individual upon a successful insurance claim.

What happens if your insurance claim is denied?

If an insurance claim is denied, an individual can review their paperwork to identify the reason behind the insurance being denied. They can then contact their insurance agents, companies, or doctor’s office to gain a better understanding of the denial.

Should an insurance company refuse to pay the claim, an individual can file an appeal, meaning that an independent third party can gain insight into the issue. When an appeal takes place, an individual would need to get an internal review, where the insurance company employees who were not responsible for the original decision go over the request for an insurance claim. Once that has been done, the insurance company will notify the individual of their decision.

Conclusion

Claiming insurance may seem like a daunting task, but at Prudential, we are here to help! We have skilled professionals who can cater to your needs and requests. Visit our website for more information on insurance that you are keen to know more about.