What is an Insurance Claim?
Insurance claims are written records submitted by policy holders to an insurance company with which they have an active policy. This submission is made in the hopes of receiving monetary benefits. The claim serves as the application form for compensation under the terms of the policy, and must be filed by the policy holder before the insurance company will release funds to any medical facility, repair shop or eligible contracted service. Submission of an application is not a guarantee of approval; the insurance company will assess the situation before approving or denying the claim, and their decision is based on an independent investigation into whether the claim is meritorious and valid based on the terms of the claimant?s policy.
Every insurance policy maintains regular payments called premiums. Whether you take out a policy for home, life, health, or automobile, your insurance premiums are the means insurance companies use to create their assets. These accounts can settle any problem you or other insured victims have. When an accident or claim occurs, whether it is a small accident or a major natural disaster, you then have the right to file a claim for restitution from your insurance company. As an injured policyholder, you want a responsive and compassionate response from your insurance company to help you through the financial difficulties you face.
Generally, you will work with an agent of the insurance company that is located in your area to file the insurance claim. The role of the agent is to review the specific elements of the claim and to work with the insurers to secure payment. In some cases, a local authority (such as a lawyer or construction contractor) may work directly with the insurance company to file the required documentation. But, if the injury is minor in nature or the issue may be settled without involving the insurance company, the policy holder can elect not file involve the insurance company by filing a claim.
Once your insurance claim is filed, an investigator (called an adjustor or appraiser),may be sent out by the insurance company. Their job as an adjustor is to evaluate your claim and determine is the amount of the claim is reasonable. This prevents fraud by contractors who may inflate bills for more compensation. Insurance companies accept the evaluation by the adjustor or appraiser as final word on claim.
Many factors come into play in determining the time period for approval or denial of a claim. One deciding factor is the date and time the claim is made by a policy holder, which has a significant effect on turnaround time. For instance if the claim is made after close of business on a Friday, the insurance company will not receive the claim for processing until they open again on the following Monday. Another factor that determines processing time is the type of evidence presented in support of the claim. If the claim is obvious and clear cut, a decision can be made on the spot. If the claim is more complicated or missing information, then it will take longer to process.
There are several reasons an insurance company may choose not to pay claims. One of the most obvious reasons is that the premiums have not been fully paid, thus inactive. In the case of automobile accidents in which one party is held responsible, the claim could be paid by another insurance company. Another reason accident or damage claims are rejected is because the policy does not cover one or more conditions outlined in the policy, such as carelessness or “Acts of God”. For example, an unavoidable “act of God” may be covered if it qualifies as a covered condition, but carelessness may not be if it is not a covered condition. If claims do not meet the specified “covered conditions” in the policy, the company has the right to deny coverage.
The only legally recognized manner of applying for benefits under an insurance policy is the filing of a claim with the insurer. However, until the insurer has completed its assessment of the circumstances, the claim will remain pending and there will be no pay-out.
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