What to do if your insurance claim is stuck?

New Delhi: Forty-six-year-old Sushila Jasraj had bought an insurance policy before undertaking the Kailash Mansarovar Yatra. During the journey, she developed a severe breathing problem and had to be evacuated by an air ambulance to a hospital in Kathmandu.

However, the insurance company rejected her claim of Rs 90,000, saying the evacuation was not necessary.

To her rescue came Mumbai-based Claimvasooli.com -- an initiative by a veteran in the non-life insurance space for the past 15 years.

Experts from Claimvasooli took up her case and after detailed investigation found that the interiors of Tibet from where she had to be evacuated were inhospitable. Her claim was settled within four months.

"We found that there is no platform for insurance claims for products like mediclaim and travel policies, among others, which are purchased through agents, banks or online. With increasing number of policies sold online and through direct channels, there is a need for an expert intermediary who can deal with claims and who can represent the aggrieved claimant," Pushkaraj Shete who set up Claimvasooli.com told IANS.

Getting an insurance online is easy. But getting claims approved is usually a cumbersome process, with companies often raising objections.

An insurance is a legal contract. The declarations (proposal form) made by the customer before the contract is executed, as well as the terms of the contract (policy wordings) legally bind both the insurer and the customer.

According to Mahavir Chopra, Director of Strategic Initiatives, Coverfox.com, "ignorance and incorrect declaration of facts while buying/renewing insurance are the two biggest reasons why claims are rejected in general insurance. Customers do not fill their proposal forms themselves or fill them casually without understanding the repercussions of making an incorrect or incomplete declaration."

Coverfox.com is a place to search, compare, buy and manage insurance online.

Just like Jasraj, something similar happened with 38-year-old businessman Dilip Mallesha who suffered from dengue and was admitted to a Mumbai clinic but his insurer refused to cover the cost.

His claim of Rs 25,083 was rejected on the argument that he was admitted only for diagnosis on the advice of his family doctor. Mallesha approached Claimvasooli. The portal's officials conducted an investigation and the results showed that the patient indeed required hospitalisation. They took it up with the company. The claim was settled.

While selling a general insurance policy, it is indeed essential for an insurance company to educate the policy buyer to avoid any doubts or confusion in future. Both the buyer and the seller must be aware of the facts.

"At the time of buying a policy, the customer is provided with complete information on the product both verbally and through product literature such as brochures, leaflets and audio-visual aids. Also, information and generic knowledge on general insurance is sent across to our customers through e-mailers and letters at varying intervals," Mick Miller, Senior Vice President-Claims, SBI General Insurance, told IANS.

To avoid rejection of claims, a policy buyer must diligently fill the proposal form himself or herself ensuring all the information declared is true.

Moreover, reading through the terms and conditions of the policy carefully, clearing all doubts with respect to benefits, processes and exclusions before signing up for the policy are some of the essential things one must take care of before buying a policy.

There are several reasons why general insurance claims are rejected.

Citing an example, Mukesh Kumar, Executive Director, HDFC ERGO General Insurance, told IANS: "A Motor insurance claim will most likely be rejected if the policyholder takes insurance for a regular private car and uses the car for commercial purposes. This is because the risk of a possible mishap increases if the vehicle is being used for commercial purpose. Another reason for the same can be failure of producing relevant documents by the policyholder at the time of filing the claim."

Claimvasooli comprises an in-house team of claims specialists and an advisory board of industry veterans. A claimant can easily contact them through their website. In addition, the organisation won't charge you anything till the claim is settled.

"We do not charge any upfront fee from a claimant. A nominal fee is charged once the claim is approved by the insurance company. This fee, to cover our direct costs, ranges from Rs 2,000 to Rs 10,000 depending on the claim complexities which is conveyed to the claimant in advance," Shete said.

According to the Insurance Regulatory and Development Authority of India (IRDAI), the regulations covering insurance brokers permit them to offer claims consultancy to their non-primary clients (clients who have not availed of the insurance broking service).

"We will take action if there are complaints about non-compliance of the regulations," P.J. Joseph, Member (Non-Life) Insurance Regulatory and Development Authority of India (IRDAI), told IANS.

Thus, if your insurance claim is stuck, don't fret. Call Claimvasooli.com.