Motivation to start Claims Bazaar and our activities

 
Motivation to start Claims Bazaar and our activities

 3Ws > What Who & Why

It is 2012, a little girl in Devarshola, a village near Gudalur, The Nilgiris District, Tamilnadu, South India, while going to school through tea plantations along with her friends suddenly falls down. This falling down occurred a few times and the parents were scolding the child “can’t you to look properly and walk” and also gave a few beatings. However, the mother being disturbed took the child to a local Ayurvedic Vaidyar (practitioner) who gave her an oil application to be used regularly. Sometime later, while the child was walking with her father on a concrete road suddenly fell down. The father, taken aback, perturbed, took the child to a Hospital in Sultans Battery, Kerala, Wynad District and was further referred to an Orth hospital at Perunthalmanna, Kerala where she was found to be having a disorder in the hip bone which was causing this fall and was operated upon and became alright. Now Mr. A had taken a Health Insurance for his family and he lodged the claim with Star health Insurance Co.  The claim was for reimbursement and the Insurer kept on sending a letter “Please send initial treatment details. If you do not send your reply within 15 days your claim will be treated as closed”.

At this stage the Founder of Claims Bazaar was approached. Claims Bazaar prepared a detailed representation about the incident and that the initial treatment was with a local Ayurvedic practitioner who had not given any prescription or notes about the problem but had only given an oil application and that the parents became cautious only when the child fell on a neatly paved concrete road and later taken to a hospital in Sultan battery and further on to Perunthalmanna Ortho Hospital and asked the Insured Mr. A to send the representation to the claims department of the Insurer.

On receiving the representation, the claim was settled in full within a fortnight.

This incident became the motivation to the founder of claims bazaar to start a firm exclusively for Insurance claims since the Insured Population may be in distress in many cases like this under various portfolios.

What are our activities in relation to a claim?

1.    When an Insured person approaches us regarding non settlement of a claim or repudiation of a claim, we collect a copy of all the documents to find out whether the said claim can be payable under the policy or not.

2.    If Payable, we prepare a representation to be sent to the grievance cell of the Insurer by the Insured person.

3.    In order to prepare the representation on why the claim is payable, Claims Bazaar refers to various decisions, similar to the case on hand, awarded by the Insurance Ombudsman, Consumer Courts ie. State Commission/National Commission or Supreme Court as a basis under which the claim becomes payable. Claims bazaar also interprets the reason on why the claim becomes payable. 

4.    If repudiation is upheld or not replied to by the grievance cell, the same is duly forwarded to the Grievance Redressal Officer of the Insurer.

5.    The Grievance Redressal Officer will send a reply regarding settlement or upholding of the repudiation.

6.    If settled well and good. If not Claims Bazaar guides the Insured person to approach the Insurance Ombudsman. Insurance Ombudsman is a mediator, established by the Government of India, and monitored by the Insurance Regulatory Development Authority and the General Insurance Council.

7.    To file a case with the Insurance Ombudsman there are certain forms designed for the same and Claims Bazaar prepares the same and sends it to the Insured person to forward to the Insurance Ombudsman within the relevant jurisdiction. For eg. A person in Coimbatore, Tamilnadu, comes under the jurisdiction of the Insurance Ombudsman in Chennai. On receipt of the same, the Insurance Ombudsman allots a grievance number and also sets a date for mediation either in person or virtually. Claims bazaar prepares the Insured for mediation.

8.    The Insurance Ombudsman awards the case or upholds the rejection. If award is received then the Insurer settles the same within the period stipulated by the Ombudsman who may also awards a compensation for delay in settlement.

9.    In our experience we find that generally all claims are settled maximum at the stage of Insurance Ombudsman. Very few have to be scaled up.

10.  In case a case has to be scaled up to the Consumer Courts, then, according to the value of the pecuniary jurisdiction (Financial limit) Claims bazaar assists the Insured person to file the case and to guide throughout the process of adjudication.

11.  Claims bazaar charges a reasonable fee upfront and after settlement of a claim a fee as agreed to will become payable. For a case to be filed with the Insurance Ombudsman there is no fees, but for cases to be filed in Consumer Courts where the value of the case exceeds Rs.5 lakhs fees will become applicable. Also, in cases where Claims bazaar assists with the help of a Lawyer, the fees for the said lawyer has to be borne by the Insured.

Who can approach Claims Bazaar?

1.    Any Insured person whose claim is pending, partially settled or repudiated can approach.

2.    Any Insurance Agent or Broker may approach to assist their client.    

3.    Any Consumer Welfare Associations may approach us to help their client.

Why approach Claims Bazaar?

The Founder has an experience of more than 30 years in the Insurance domain and also has been a Member of the District Consumer Disputes Redressal Commission for a period of 5 years. The other consultants connected to Claims Bazaar are also experts in Insurance Domain with more than 30 plus years.

Our Success rate:

Till now Claims Bazaar has handled about 60 cases and 90% have been successful.