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MEDICAL AND HEALTH INSURANCE

CHAPTER 5: CLAIMS AND POLICY ADMINISTRATION

INTRODUCTION

The various administrative functions in the service of medical and health insurance

policy policies are an important part of an insurance company's operations. The after
sales service in the form of policy administration and claims servicing procedures are

critical to the success of insurance operations. The claims department is responsible

for honoring the financial promissory notes in the form of insurance policies of the

company. In this Chapter, we will discuss the principles, practices, and processes in

depth.

5.1 MEDICAL AND HEALTH CLAIMS PROCEDURES
The claims manual of an insurance company will set out the claims procedures on

how claims are notified and processed up until the full settlement and recoveries, if

any, or litigation procedures to be undertaken. The claims procedures that the

Insured is required to comply with also form part of the policy terms and conditions in

the insurance contract

The typical claims procedures are detailed as below:

1. NOTIFICATION/REPORT OF CLAIM

a) Claim notification received from intermediaries or direct clients stating the full

particulars of such events, including all original bills/invoices, receipts and medical

reports stipulating the medical condition being treated.

b) Notice must be within 30 days from the date of loss or hospitalization.

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