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Claim Assessment | Meaning & How It Works

Claim assessment in health insurance refers to the process of evaluating the merits of a claim raised by a policyholder. The claim assessment process includes screening all the information provided in the claim form, verifying details, checking for all the required documents, assessing the admissibility of the claim and taking a decision on the payout to be made.

The quality of the claim assessment process followed by a health insurer largely determines the claim experience of its customers. Streamlining the process, creating a claim assessment checklist and following the best practices enhances claim processing efficiency and reduces the time taken to settle each claim, ensuring greater customer satisfaction. It is also in the insurer’s best interest as it minimises risk by reducing unnecessary payouts.

Want to understand the health insurance claim process? Here are the common steps that a claim cycle can take:

[1] Filing a claim: You fill out the claim form and provide the necessary information and documents.
[2] Claim assessment: Your insurer evaluates the claim based on the information provided by you and the terms of your policy.
[3] Seeking further information: If any document or information is missing, the insurer asks you to provide the same.
[4] Claim approval and settlement: If the insurer finds the claim admissible and valid, the claim amount payable is decided based on the coverage terms. The insurer pays this amount to you. In case some documents are missing, the claim is inadmissible or waiting periods or exclusions apply, the insurer rejects your claim. If the insurer believes that the claim is fraudulent, it can repudiate the claim and take legal action against the claimant.
[5] Claim closure: After the claim is paid, the insurer officially closes the claim. 

 

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