Brilliant Review Corner

What is an Insurance Claim?

What is an Insurance Claim?

Article by Graham McKenzie

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.

People who purchase health, life, auto, or home insurance have to pay premiums (regular payments) to their insurance company or companies. The insurance companies usually use the premiums to settle the claims other people make or to boost their capital reserves and assets. When accidents and natural disasters cause severe financial damage, such as car wrecks, hurricanes and tornadoes, or large-scale accidents in the workplace, the policy holder can file a claim. He or she can then receive money from the insurance company to cover the costs outlined in his or her policy.

Usually insurance claims are filed with the insurer’s local representatives. This person will become liable for checking out the particular details of the claim and then negotiating payments from the primary insurers. Usually, a recognized expert such as a building contractor, repair shop, or physician will file the needed insurance claim forms with the insurer directly. But at other times, the policy holder might not wish to file a true insurance claim if there are only minor damages or if the other party has chosen to pay for their mistake out-of-pocket.

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.

Several things affect how long it takes an insurance company to approve or deny a claim for payment. The day and time when the policy holder makes the claim can affect turnaround time. For instance, claims made on a Friday afternoon or evening, Saturday, or Sunday are often not processed until Monday. Additionally, the evidence presented can affect the process. Self-evident claims can be processed fairly quickly because the evidence is straightforward. More complicated claims can take longer to process, as the insurance company may decide to investigate the case further, and police reports, property assessments, etc. may come into play.

There are a multitude of reasons why an insurance company would not approve an insurance claim. The most obvious reason would be if the individual holding the policy (the claimant) has not paid his or her premiums; this renders the policy invalid. In cases where multiple individuals and policies are involved, another insurance company may have paid for services. This is most common for auto policies; the insurance company of the party responsible for the accident will most often be required to pay. Lastly, the payment requested must be for something covered in the policy. Several examples of claims that might not be covered are “Acts of God”, an accident or damage caused by an unavoidable storm, and damage caused by recklessness or carelessness. It is always a good plan to read your policy closely to determine whether or not you qualify for benefits.

The only way to request payment under the terms of a policy of insurance is to complete an official claim form. However, whilst the insurance company is reviewing the circumstances it stays as just a claim, and payment is not guaranteed.