Common use of Claims Assessment & Repudiation Clause in Contracts

Claims Assessment & Repudiation. (i) At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised by Us in writing. If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents. (ii) We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay. (iii) We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In case of any suspected fraud, the last “necessary” document swill include the receipt of the investigation report from Our investigator/representatives. (iv) Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate. (v) In case of delay in payment, We shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. For details on the claims process or assistance during the process, the claimant may contact Us at Our call centre on the toll free number specified in the Policy Schedule or Certificate of Insurance or through Our website. In addition, We will keep the claimant informed of the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our Website.

Claims Assessment & Repudiation. (i) a. At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised authorized by Us in writing. If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents. (ii) We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay. (iii) b. We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In case of any suspected fraud, the last “necessary” document swill shall include the receipt of the investigation report from Our investigator/representatives. (iv) Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate. (v) In case of delay in payment, We shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. c. Payment for Reimbursement claims will be made to You. For details on In the unfortunate event of Your death, We will pay the Nominee named in the Schedule of Insurance Certificate or Your legal heirs or legal representatives holding a valid succession certificate. d. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into consideration the available Sum Insured in these Policy Periods including the Deductible for each Policy Period. Such eligible claim amount will be paid to the Policyholder/Insured Person after deducting the extent of premium to be received for the Renewal/due date of premium of the Policy, if not received earlier. e. All admissible claims process under this Policy shall be assessed by Us in the following progressive order:- i. If a room has been opted in a Hospital for which the Room Rent or assistance during room category is higher than the process, the claimant may contact Us at Our call centre on the toll free number eligible limit as applicable for that Insured Person as specified in the Policy Schedule or Certificate of Insurance Certificate, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with Section 2.1c. ii. The Deductible (if applicable) shall be applied to the aggregate of all claims that are either paid or through payable under this Policy. Our websiteliability to make payment shall commence only once the aggregate amount of all claims payable or paid exceeds the Deductible. iii. In addition, We will keep Co-payment (if applicable) shall be applicable on the claimant informed amount payable by Us as specified in the Schedule of Insurance Certificate. f. The claim amount assessed in Section 9.4 e above would be deducted from the claim status amount mentioned against each benefit and explain requirement Sum Insured as specified in the Schedule of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our WebsiteInsurance Certificate.

Claims Assessment & Repudiation. (i) a. At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised authorized by Us in writing. If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents. (ii) We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay. (iii) b. We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In case of any suspected fraud, the last “necessary” document swill shall include the receipt of the investigation report from Our investigator/representatives. (iv) Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate. (v) In case of delay in payment, We shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. c. Payment for Reimbursement claims will be made to You. For details on In the unfortunate event of Your death, We will pay the Nominee named in the Schedule of Insurance Certificate or Your legal heirs or legal representatives holding a valid succession certificate. d. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into consideration the available Sum Insured in these Policy Periods including the Deductible for each Policy Period. Such eligible claim amount will be paid to the Policyholder/Insured Person after deducting the extent of premium to be received for the Renewal/due date of premium of the Policy, if not received earlier. e. All admissible claims process or assistance during under this Policy shall be assessed by Us in the process, following progressive order:- i. If a room has been opted in a Hospital for which the claimant may contact Us at Our call centre on room category is higher than the toll free number eligible limit as applicable for that Insured Person as specified in the Policy Schedule or Certificate of Insurance Certificate, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with Section 2.1c. ii. The Deductible (if applicable) shall be applied to the aggregate of all claims that are either paid or through payable under this Policy. Our websiteliability to make payment shall commence only once the aggregate amount of all eligible claims as per policy terms and conditions exceeds the Deductible limit within the same Policy Year. iii. In addition, We Co-payment (if applicable) as specified in the Schedule of Insurance Certificate shall be applicable on the amount payable by Us. f. The claim amount assessed in Section 7.4 e above would be deducted from the amount mentioned against each benefit and Sum Insured as specified in the Schedule of Insurance Certificate. The re-fill amount will keep be applied only once the claimant informed of Base Sum Insured and No Claim Bonus is exhausted in the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our WebsitePolicy Year.

Claims Assessment & Repudiation. (i) a. At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised authorized by Us in writing. If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents. (ii) We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay. (iii) b. We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In case of any suspected fraud, the last “necessary” document swill shall include the receipt of the investigation report from Our investigator/representatives. (iv) Payment for reimbursement claims will be made to the Insured Person. In the unfortunate event of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate. (v) In case of delay in payment, We shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. c. Payment for Reimbursement claims will be made to You. For details on In the unfortunate event of Your death, We will pay the Nominee named in the Schedule of Insurance Certificate or Your legal heirs or legal representatives holding a valid succession certificate. d. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into consideration the available Sum Insured in these Policy Periods including the Deductible for each Policy Period. Such eligible claim amount will be paid to the Policyholder/Insured Person after deducting the extent of premium to be received for the Renewal/due date of premium of the Policy, if not received earlier. e. All admissible claims process under this Policy shall be assessed by Us in the following progressive order:- i. If a room has been opted in a Hospital for which the Room Rent or assistance during room category is higher than the process, the claimant may contact Us at Our call centre on the toll free number eligible limit as applicable for that Insured Person as specified in the Policy Schedule or Certificate of Insurance Certificate, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with Section 2.1c. ii. The Deductible (if applicable) shall be applied to the aggregate of all claims that are either paid or through payable under this Policy. Our websiteliability to make payment shall commence only once the aggregate amount of all claims payable or paid exceeds the Deductible. iii. In addition, We will keep Co-payment (if applicable) shall be applicable on the claimant informed amount payable by Us as specified in the f. The claim amount assessed in Section 9.4 e above would be deducted from the amount mentioned against each benefit and Sum Insured as specified in the Schedule of the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our WebsiteInsurance Certificate.

Claims Assessment & Repudiation. (i) a. At Our discretion, We may investigate claims to determine the validity of a claim. This investigation will be conducted within 15 days of the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. All costs of investigation will be borne by Us and all investigations will be carried out by those individuals/entities that are authorised authorized by Us in writing. If there are any deficiencies in the necessary claim documents which are not met or are partially met. We will send a maximum of 3 (three) reminders following which We will send a rejection letter or make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents. (ii) We may decide to deduct the amount of claim for which deficiency is intimated to the Insured Person and settle the claim if We observe that such a claim is otherwise valid under the Policy. However documents/ details received beyond such period shall be considered if there are valid reasons for any delay. (iii) b. We shall settle or repudiate a claim within 30 days of the receipt of the last necessary information and documentation set out above. In However, where the circumstances of a claim warrant an investigation in Our opinion, We shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of any suspected fraud, the last “necessary” document swill include the receipt of the investigation report from Our investigator/representatives. (iv) Payment for reimbursement claims will be made to the Insured Personlast necessary document. In such cases, Insurer shall settle the unfortunate event claim within 45 days from the date of the Insured Person’s death, We will pay the nominee named in the Policy Schedule or Certificate receipt of Insurance, or to the Insured Person’s legal heirs or legal representatives holding a valid succession certificate. (v) last necessary document. In case of delay in payment, We shall be liable to pay interest at a rate which is 2% above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by Us. c. Payment for Reimbursement claims will be made to You. For details on In the unfortunate event of Your death, We will pay the Nominee named in the Policy Schedule or Your legal heirs or legal representatives holding a valid succession certificate. d. If a claim is made which extends in to two Policy Periods, then such claim shall be paid taking into consideration the available Sum Insured in these Policy Periods including the Deductible for each Policy Period. Such eligible claim amount will be paid to the Policyholder/Insured Person after deducting the extent of premium to be received for the Renewal/due date of premium of the Policy, if not received earlier. e. All admissible claims process under this Policy shall be assessed by Us in the following progressive order:- i. If a room has been opted in a Hospital for which the room category is higher than the eligible limit as applicable for that Insured Person as specified in the Policy Schedule, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with Section 2.1c. ii. The Deductible (if applicable) shall be applied to the aggregate of all claims that are either paid or assistance during payable under this Policy. Our liability to make payment shall commence only once the process, aggregate amount of all eligible claims as per policy terms and conditions exceeds the claimant may contact Us at Our call centre on Deductible limit within the toll free number same Policy Year. iii. Co-payment (if applicable) as specified in the Policy Schedule or Certificate of Insurance or through Our websiteshall be applicable on the amount payable by Us. f. The claim amount assessed in Section 7.4 e above would be deducted from the amount mentioned against each benefit and Sum Insured as specified in the Policy Schedule. In addition, We The re-fill amount will keep be applied only once the claimant informed of Base Sum Insured and Increased Sum Insured under I-Protect (if applicable) are exhausted in the claim status and explain requirement of documents. Such means of communication shall include but not be limited to mediums such as letters, email, SMS messages, and information on Our WebsitePolicy Year.