Health Insurance - Claim Intimation

Health Insurance Claim Intimation

What is claim intimation in Insurance

Claim intimation is the purposeful act of informing the insurer or TPA on a potential invoking of benefits under the insurance contract. This could be a claim typically under hospitalisation for long term duration, day care,  OPD and as well under other policies including Personal Accident cover and Life Insurance cover. This applies for group policies as much as retail / individual insurance covers

What is the purpose of claim intimation

There are a few things that the insurer does once they get a formal intimation of a claim 

1. They reserve funds to meet that up coming and ongoing claim
   
2. They may want to set up an investigator to check on the genuineness of a claim
   

1. Claim Intimation for Health Insurance
   
1. Group Health Insurance (GMC / GHI)
   
2. Retail Health Insurance ( Family Floater or Individual)
   
2. Claim Intimation for Life Insurance
   
1. Group Term Life Insurance (GTLI)
   
2. Retail Term Life Insurance
   
3. Claim Intimation for Personal Accidental Insurance
   
1. Group Personal Accident Insurance (GPA)
   
2. Individual  Personal Accident Insurance (IPA)
   

We reckon you may have an insurance claim coming up if you are reading this article. 

Aligned to this policy term, please note the below mentioned format for intimating a claim under a health insurance policy. The intimation needs to be done on specific email ids and phone numbers. The list for the same can be accessed here

Policy No and Id card No
Corporate Name ( in case of corporate / group policies )
Employee Code ( in case of corporate / group policies )
Employee Name / Policy Holder Name
Patient Name
Name of Hospital
Address of Hospital
Ailment/ Diagnosis
Date of Admission

When should claim intimation be done

The timelines for claim intimation vary from insurer to insurer. For Health Insurance policies, the insurers ask for the claim intimation to be done within 24 hours of hospitalisation for emergency admissions and 48 hours prior to admission for  planned treatments.   The policies have a clause for denial of claim in case this is not done

What if claim intimation is not done within the stipulated timeline

In case you have not done claim intimation within the timeline, the regulator has clearly clarified that upon submission of valid inability to do claim intimation ( or claim submission ), the insurer can waive off this requirement and condone the delay. 

Difference between claim intimation and claim submission  
Also linked is the claim form which you need to fill and submit along with all hospitalisation records. Ideally we recommend that you submit these within 7 days of discharge and not exceeding 15 days. This will ensure that the insurer does not invoke the clause of delay in claim submission which itself will make it difficult to have your claim processed within time.

May you need any further information / clarification or support, please send a mail back to us. 

Wishing you and family Happy Health, once again.

Happy to Help

Team PlanCover.com

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