An Overview
The truth of insurance is realized when an insured event occurs and claims are filed. We buy life, health, or general insurance with the hope that the insurance company will honor the claim.
However, there can be instances when the insurance company repudiates the claim, short settles it, or rejects it by forfeiting the paid premium. In such cases, the insured person or family often blames the company without fully understanding the responsibility of the insurance company. Conceptually, insurance works on the principle of creating a pool of people facing similar risks and claims. These people pay premiums to create funds so that losses can be compensated for a few unfortunate individuals who suffer a loss. The insurance company is merely the manager of the pool, and claims are paid out through contributions from all pool members. It is the responsibility of the insurance company to investigate all claims thoroughly to ensure that no one takes undue advantage of the system. However, some genuine claims are also repudiated in the process and may require representation for the claim to be honored.
Guidelines for Dealing with Denied Insurance Claims
Once you understand the process, it’s crucial for the insured to follow the guidelines provided by the insurance company and submit the claim. All discrepancies should be addressed by mentioning the claim number to ensure proper documentation.
An insurance company is supposed to provide a decision within 15 days of receiving all the required documents. In case the claim is repudiated or delayed, the insured person or family should follow the guidelines listed below:
1) Review the Denial Letter: Carefully review the denial letter sent by your insurance company. This letter should provide reasons for the denial and reference specific policy provisions. Understanding the grounds for denial is crucial as it will help you address the issue effectively. If you believe that the denial reason is not valid, you can write to the company with your counterargument and supporting evidence.
2) Write to the Customer Care/Grievance Cell of the Insurance Company: All insurance companies maintain an escalation matrix that you should follow. If you feel that the denial reason is not valid, write to the company with your counterargument and evidence and appeal against the decision. IRDAI (Insurance Regulatory and Development Authority of India) allows the insurer to respond within 14 days for any complaint raised.
3) IRDAI – Bima Bharosa: If you are not satisfied with the company’s decision, you can register your complaint with IRDAI.
4) Consult Experts: It’s essential to present your case effectively, so seeking help from experts like Insurance Samadhan, who understand the rules and regulations, can assist you in drafting a strong complaint letter.
5) Contact the Insurance Ombudsman: If your insurance company does not resolve your claim to your satisfaction, you can approach the Insurance Ombudsman. This is an independent body set up by the Government of India to address policyholders’ grievances and mediate disputes between policyholders and insurers.
6) Legal Action: As a last resort, you can consider taking legal action against the insurance company. Consult with a legal expert specializing in insurance claims to assess the viability of pursuing legal action. Litigation should only be considered when all other avenues have been exhausted.
Bottom Line
Facing a denied insurance claim can be a stressful and challenging experience, but it’s essential to know that you have options for recourse in India. By following the steps outlined in this article, you can increase your chances of having your claim approved or finding a resolution to your satisfaction. Remember to stay persistent, gather evidence, and seek professional advice when necessary to navigate the complex process of dealing with a denied insurance claim.
Feel free to contact us for assistance with your insurance-related issues. We’ll be happy to help you.
Please note that “Insurance Samadhan” is a private organization and is not associated with IRDA or any government body.
By Shilpa Arora – Co-founder & COO
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