Common use of Claims Assessment & Repudiation Clause in Contracts

Claims Assessment & Repudiation. a. At the Company discretion, the Company may investigate claims to determine the validity of a claim. All costs of investigation will be borne by the Company and all investigations will be carried out by those individuals/entities that are authorized by the Company in writing. b. The Company 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 shall include the receipt of the investigation report from the Company investigator/representatives. In case of delay in payment, the Company 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 the Company. c. Payment for Reimbursement claims will be made to the Insured Person. In the unfortunate event of Insured Person’s death, the Company will pay the Nominee named in the Certificate of Insurance or his legal heirs or legal representatives holding a valid succession certificate. d. All admissible claims under this Policy shall be assessed by the Company 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/ Certificate of Insurance, then the Associated Medical Expenses payable shall be pro-rated as per the applicable limits in accordance with Section 2.1c. ii. Co-payment (if applicable) shall be applicable on the amount payable by the Company as specified in the Policy Schedule/ Certificate of Insurance The claim amount assessed in Section 6.4 d above would be deducted from the amount mentioned against each benefit and Sum Insured as specified in the Policy Schedule/ Certificate of Insurance.

Claims Assessment & Repudiation. a. At the Company Our discretion, the Company We may investigate claims to determine the validity of a claim. All costs of investigation will be borne by the Company Us and all investigations will be carried out by those individuals/entities that are authorized by the Company Us in writing. b. The Company 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 shall include the receipt of the investigation report from the Company Our investigator/representatives. In case of delay in payment, the Company 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 the CompanyUs. c. Payment for Reimbursement claims will be made to the Insured PersonYou. In the unfortunate event of Insured Person’s Your death, the Company We will pay the Nominee named in the Certificate Schedule of Insurance Certificate or his 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 under this Policy shall be assessed by the Company 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/ Certificate Schedule of InsuranceInsurance 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 payable under this Policy. Our liability 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. Co-payment (if applicable) as specified in the Schedule of Insurance Certificate shall be applicable on the amount payable by the Company as specified in the Policy Schedule/ Certificate of Insurance Us. f. The claim amount assessed in Section 6.4 d 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 be applied only once the Base Sum Insured and No Claim Bonus is exhausted in the Policy Schedule/ Certificate of InsuranceYear.