What Are the Insurance Coverage and Claim Amount Details?

Dear Suresh P v ji

We understand that you want to know how insurance claims work, how much claim money you may receive, and how to check your claim status. The claim amount depends on your insurance type, policy coverage, sum insured, actual expenses or losses, and the terms and conditions of your policy. There is no fixed claim amount that applies to every policyholder.

What is an insurance claim amount?

An insurance claim amount is the money an insurance company pays or approves when a covered event occurs and the claim meets the policy conditions. The amount you receive depends on the type of insurance and the benefits included in your policy.

How is the insurance claim amount calculated?

• Health insurance: The insurer may pay eligible hospital expenses directly to the hospital through cashless treatment or reimburse eligible expenses you have already paid. The payout depends on your sum insured, policy limits, deductibles, co-payment, exclusions and other applicable conditions.
• Life insurance: The payout depends on the policy benefit. It may include the sum assured and applicable bonuses, depending on the policy and whether the claim is for death, maturity or another covered benefit.
• Motor insurance: The claim amount depends on the type of cover, assessed vehicle damage, repair costs, applicable deductibles, depreciation and policy limits.
• Home or property insurance: The payout depends on the covered damage, the loss assessment, the insured value and the policy's exclusions and limits.

What is the difference between the claimed amount and the approved amount?

• Claimed amount: The amount requested by you or the hospital.
• Approved amount: The amount accepted by the insurer after checking the policy and claim documents.
• Paid amount: The amount actually paid to you or the hospital.
• Rejected amount: The amount the insurer does not approve, with the reason explained in its decision.

The approved amount may be lower than the claimed amount if certain expenses are not covered or policy limits apply.

How can you check your insurance claim status?

1. Visit your insurance company's official website or mobile app.
2. Open the Claims or Track Claim Status section.
3. Enter the required policy number, claim number or other requested details.
4. Check whether the claim is under review, approved, partially approved, settled or rejected.
5. If the amount is unclear, contact the insurer and request a claim settlement statement explaining the approved amount, deductions and any unpaid balance.

What documents be required?

The documents depend on the type of insurance and claim. Commonly required documents include :

• Insurance policy details or policy number.
• Claim form and claim reference number.
• Identity proof and bank details, where applicable.
• Supporting bills, receipts and other proof of expenses or loss.
• Additional documents requested by the insurer for your specific claim.

For health insurance, the insurer may also ask for hospital bills, discharge summaries, prescriptions, investigation reports and medical records. For life insurance death claims, a death certificate and nominee documents may be required. Motor claims may require vehicle registration, driving licence, photographs and repair estimates, depending on the case.

What do Claim Settlement Ratio and Incurred Claim Ratio mean?

• Claim Settlement Ratio (CSR): Shows the proportion of claims settled by an insurer during a specified period. Check how the insurer calculates and reports this figure, as it may differ by insurance type and claim category.
  
  
• Incurred Claim Ratio (ICR): For health and general insurance, this generally compares claims incurred by an insurer with the premiums earned during a specified period. It is not the percentage of individual claims that will be paid.

These figures can help when comparing insurers, but they do not guarantee that your individual claim will be approved or paid in full.

How can you find old or unclaimed insurance money?

If you think an old policy has an unpaid amount, first contact the relevant insurance company through its official website or customer service channel. You can also visit the official IRDAI Bima Bharosa portal for insurance-related grievance information. Confirm the appropriate process for locating and claiming unclaimed policy proceeds with the insurer. Never share your OTP, password or banking PIN with anyone claiming to help recover your money.

Wishing you and your family good health always.
Warm regards,
Team HexaHealth