The difficulty of managing insurance claimsInsurance claim A formal request made to the insurance company for compensation based on the terms of the insurance policy or agreement. is often a scourge for insurance policyholders. Not a few also make this one of the reluctance to buy an insurance policyInsurance policy An agreement between the policyholder and the insurance company to perform the obligations as agreed by both parties., be it health insurance, car insurance, or travel insurance. However, the difficulty of processing these claimsClaim The demands are given by the insurance policyholder to get the right properly so that the insurer pays the conditions according to the existing procedure. is not without reason. Everything is in the agreement between the insurerInsurer A person who is legally listed in the insurance policy to make premium payments for that policy. and the buyer of the insurance policy and is legally bound. This means claims will not be carelessly rejected.
Here are the reasons for the rejection of your insurance claimInsurance claim A formal request made to the insurance company for compensation based on the terms of the insurance policy or agreement.:
The policyPolicy The policy is a binding agreement and is agreed upon by the insurance company and policyholder in writing. An agreement made by the policyholder with an insurance company. is Inactive (LapseLapse Premiums that are not paid beyond the grace period can invalidate the policy (the effective period of the policy stops).)
Insurance policiesInsurance policy An agreement between the policyholder and the insurance company to perform the obligations as agreed by both parties. can be in an inactive state due to several circumstances. This inactive state is also known as a lapse. The insurer is not willing to pay insurance claims when the policy is in lapse. Here are two examples of situations where the policy is being lapsed and your insurance claim is rejected.
- Payment of insurance premiumsPremium The money that must be paid at a certain time is the obligation of the insurance policyholder. The amount of premium paid is determined by the policy and approval of the insurance company in accordance with the conditions of the insured. The nominal payment approved by policyholders and insurance companies. Premium payment will be made according to the agreement, it can be monthly, yearly, or according to the agreement. is due because it has passed the grace periodGrace period The time period after the premium due date where the premium can still be paid without being subject to interest and the policy can still be accounted for. The term used to describe the grace period given to policyholders for 30 days from the due date of payment. The deadline was given by the insurance company to the policyholder to pay the agreed premium.. Each insurance may have a grace period that is different. Usually a maximum of about 45 days. If the incident occurs after that period, the insurance will not be responsible for any losses suffered by the policyholder, even if it is included in the policy clauseClause The articles contained in the policy agreement that policyholders and insurance companies must comply with.. Pay the insurance premiumPremium The money that must be paid at a certain time is the obligation of the insurance policyholder. The amount of premium paid is determined by the policy and approval of the insurance company in accordance with the conditions of the insured. The nominal payment approved by policyholders and insurance companies. Premium payment will be made according to the agreement, it can be monthly, yearly, or according to the agreement. on time or at least not until the end of the grace period.
- If the insurance policy is in the form of a unit link, the policy can be considered a lapse if the cash valueCash Value Total money was given by the insurance company to policyholders (cash value). of the insurance is not sufficient to cover the cost of insurance. There are at least two reasons for this insufficient cash value, namely poor investment performance and frequent cash disbursements. To avoid this, it is better to do a top-up at a certain time when the investment performance is poor. In addition, make sure not to cash out the value, unless you are in a state of urgency at any time.
Claims Not Covered by a Clause
The insurance policy contains an agreement that includes the criteria for what is and is not covered by insurance. In TLO car insurance, what is meant by serious damage can vary from one insurance to another. It could be at least 70%, 75%, even 80%. Thus, insurance will not cover damage financing, if the damage does not reach the agreed percentage.
We take another example. For example, the policy states that a stroke is a cerebral-vascular attack, permanent neurological, in more than 24 hours. Even if a doctor diagnoses a policyholder with a stroke, but it is still less than 24 hours, an insurance claim cannot be filed because it will definitely be rejected.
Submission of Claims Beyond the Allotted Time
Insurance claims can be delayed or even rejected if the claim processing exceeds the time specified in the policy. Insurance always provides a certain time limit for processing claims. Through that, the claim can be rejected. Car insurance claims must be taken care of immediately because the time limit is short, only 3 x 24 hours. Meanwhile, for insurance such as life insurance, the time limit is between 30-60 days.
Incomplete Claim Documents
Make sure you know all the documents that must be provided when you want to submit a claim. One missing document, the insurance will reject the claim. For example, for life insurance, a certificate from a doctor is required. You are also required to fill out a claim form.
Follow the procedure properly. If the claim submitted is a car insurance claim, be sure to take photos of the car damage. This photo will be one of the proofs when you want to submit a claim to insurance.
Next, prepare complete documents, starting from a photocopy of the insurance policy, a copy of the driving license and vehicle registration certificate, and of course the claim submission form. A police certificate may also be required in the event of serious damage.
When filling out the form, fill it honestly and clearly because the insurance company will check it later. They will not pay a claim if the claim form is proven to contain lies.
Another procedure that is no less important is making repairs at partner workshops. The same thing also includes going to a hospital that is referred to by insurance. Not allowed to repair or seek treatment in a place outside of the insurance referral.
Being in the Waiting PeriodWaiting Period The period after the policy is issued in which the insurance policy does not cover the insured's medical expenses until a certain period. The period when there is no premium payment due to certain reasons.
In certain types of insurance, there is usually a policy called a waiting period. Insurance policy buyers will not be able to submit claims if they are in the waiting period. For the critically ill, there will usually be a waiting period of around 30 to 365 days.
Say the waiting period is around 30 days. The insurance policy was purchased on April 14, 2021. Then he became critically ill on May 14, 2021. If he made a claim, the insurance would reject him, because he had not passed the waiting period.
Disease Preexisting Before Policy Purchased
Policy owners will also be denied claims if they hide their illness when purchasing a claim. Even if the waiting period has passed, if it is proven that the disease has actually been experienced since before purchasing the policy, the insurance will reject the claim. So, make sure you are still in good health when buying insurance.
Submission Claims Including Exceptions
In addition to regulating matters that include insurance coverage, the policy also regulates exemptions. These exceptions are things that are not covered by insurance. In life insurance, these exceptions include death by suicide, court punishment, or crime.
For car insurance, the exceptions that make a claim rejected include vehicles that are not functional or modified without notifying the insurer. An example of a vehicle that is not functioning according to its designation is using a motorbike to transport goods that exceed its capacity.
As for the case of motorized vehicle modifications, make sure you always notify the insurance and make sure that modifications are allowed. Do not let non-standard modifications be the cause of the accident. If this is the case, the insurance will not be willing to cover the cost of repairs.
Policyholders violate the law
Another reason that an insurance claim is rejected is if the policyholder commits an act against the law. For example, if he has all-riskRisk Risk is a loss that occurs to the insured individual or object. Various bad possibilities could happen to someone. car insurance and then his car has an accident due to recklessness or traffic violations, he cannot file a claim. The same is true if the policyholder does not have a driver’s license when driving, parking anywhere, and getting drunk.
A health insurance policyholder will also not be able to file a claim if, for example, he is seriously injured as a result of being beaten by a mob while committing a crime. The insurance policy is always compliant with applicable laws, so it is impossible to accommodate things that occur because of violations of the law.
Committing an insurance crime
What is meant by insurance crime is an act of lying or sabotage that is deliberately committed by the policy owner or his heirsHeir The name of the person listed in the insurance policy as the party receiving compensation in the event of death to the Insured. so that the insurance claim is paid. An insurance policy owner may injure himself, burn his own house, or intentionally cause an accident to get compensation from insurance.
The insurer will automatically reject the claim if after investigation it is found that the action was intentional. The same is true if an heirHeir The name of the person listed in the insurance policy as the party receiving compensation in the event of death to the Insured. commits a crime against the policy owner in order to get a claim from insurance.
Event Area Not Included in Insurance Services
Insurance policies may also include clausesClause The articles contained in the policy agreement that policyholders and insurance companies must comply with. regarding territories in the agreement. Claims are only served when the incident occurs in a certain area. If a person has insurance for his life in Indonesia and the policy states that a claim can only be filed if he dies in Indonesia, it means that the claim will be rejected if he goes abroad for treatment and dies there.
Limit Has Exceeded
Everyone agrees that the customer is king. Even so, each customer cannot arbitrarily make their own decisions, because customers must also follow the rules or regulations that have been applied to financial institutions, including insurance.
Each insurance company determines the maximum claim value that can be realized. If customers frequently make claims, the limit will run out. For subsequent claims, the insurance company will refuse.
The company does not guaranteeWarranty Statement A statement issued by a potential customer regarding the condition of the person or thing insured. insurance anymore
Each company collaborates with insurance to serve as a permanent employee benefit. This insurance is valid as long as the employee works at the company. When the employee has resigned from the company, the employee can no longer claim the insurance previously provided by the company.
Claims outside the specified list of partners
If you make a cashless claim on insurance, then you cannot claim the insurance outside the predetermined list of partners. You can only claim insurance at partners who have collaborated with the insurance you choose.
Pay close attention
There are many reasons for rejection of your insurance claim and one of the best ways to find out is to examine, study, and understand the contents of the policy. Many policyholders ignore this and end up losing money because of their own mistakes.
Every policy owner must pay close attention to any circumstances that make his claim approved or not. Every definition and explanation in the clause must be understood correctly. It takes time to understand it because the language used is a legal language that is difficult for the average person to understand. However, learning this will go a long way when he needs to file a claim later.
Make sure to avoid things where the claim is rejected. If you feel dissatisfied with the reason for the rejection of the insurance company, there is a special agencyAgent People who work and are tied to insurance companies to find and serve policyholders. Insurance company employees who are tasked with marketing products or serving prospective customers, starting from submitting the policy provisions to the contents of the policy agreement after becoming a policyholder. that deals with cases of disputes like this. Policy owners can take the case to court.
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