PremiumThe principal objective of the claim intimation clause is to ascertain if a policy exclusion such as the person being ‘under the influence of alcohol’, is applicable. Also, any kind of foul play can be ascertained via quick investigation.
My father died in a car accident on 23 October 2021. He had an accidental insurance policy. Unaware about the policy, we intimated the company on 10 December 2021 which is 15 days later than the company’s condition, which says,“Upon the happening of any event, which may give rise to claim under this Policy, written notice with full particulars must be given to the company immediately. In case of death, written notice also of the death must, unless reasonable cause is shown, be so given Before internment, cremation and in any case, within one calendar month after the death."
Now, the company doesn’t respond to countless mails to grievance officer nor does it respond to my application raised against the repudiation. Is this 15-day delay a valid ground to repudiate an accidental insurance?
- Name withheld on request
While the policy condition stipulates intimation within a specified period, insurers regularly condone the delay. Such relief is granted when a ‘reasonable cause is shown’. In your request letter, you should specify the reason for the delay. The insurance regulator has also specified that insurers must use this clause of delayed intimation very selectively.
In the case of a car accident, you would have the police FIR, the subsequent hospitalization papers and likely the post-mortem report. So, it is reasonable to expect from the insurer to process the claim based on the above documents.
The principal objective of the claim intimation clause is to ascertain if a policy exclusion such as the person being ‘under the influence of alcohol’, is applicable. Also, any kind of foul play can be ascertained via quick investigation.
If the grievance officer is not responding, you could file this claim with the insurance ombudsman, which will take a more objective look into it.
What is the procedure to avail cashless facility? Is cashless better than reimbursement?
- Name withheld on request
To avail cashless, you need to approach the insurance desk at the hospital. The desk would share your proof of insurance along with the treatment papers and the cost estimate of hospitalization, with the insurer. The insurer will then issue an authorization letter. Based on this letter, the hospital would allow your admission without any upfront payment. At the time of discharge, the hospital would send the final bill and the discharge summary to the insurer. Now, the insurer would issue the final approval amount based on these papers. This approval amount will be deducted from your total bill, and would be paid directly by the insurer to the hospital.
Insurers generally have a set of discounts negotiated with their network hospital. When the claim is processed via cashless, such discounted price is applied. Among insurers, the cost differences in the same hospital, for the same package, could be upto 50%. A lower tariff also ensures less utilization of your sum assured. Additionally, cashless process ensures that all the documentation happens between the hospital and the insurer, saving the hassle of claiming for reimbursement.
Abhishek Bondia is principal officer and managing director, SecureNow.in.
