Lesson 3 of 3 · 8 min
What a refusal has to carry
A claim cannot be turned down by one person on a desk. It needs a committee's approval, and the refusal must point at the clause it relies on.
A refused claim usually arrives as a sentence: the claim is not payable under the terms of the policy. That sentence is not enough, and knowing why is the difference between accepting a decision and being able to test it.
No claim may be turned down without the approval of the insurer's product management committee or a three-member sub-group of it called the Claims Review Committee. So a refusal is a committee decision by design, not one assessor's reading. And where a claim is refused or only partly allowed, the details have to be conveyed to the claimant with full particulars, referring to the specific terms and conditions of the policy document relied on.
One more rule matters when a family holds more than one policy. Under indemnity cover, the claimant chooses which policy to claim under, and that insurer becomes the primary one. If the claim is larger than that policy covers, the primary insurer has to seek out the other policies and coordinate settlement of the balance — without putting the coordination work on the policyholder.
A claim has been refused. What do you have?
Does the refusal name a specific clause of the policy?
Check yourself
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Kabir asks
Who has to approve a health claim being repudiated?
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