Insurance Claims in India: The Real Playbook

(Health, Car, Fire, and Term—what to do, what to submit, how settlement is calculated, and what to do if things go wrong.)

Most people treat insurance like a parachute.

They buy it, forget it, and assume it will “just work” when needed.

Then a claim happens… and suddenly you’re doing paperwork while already stressed. That’s when claims go wrong—not because the insurer is always unfair, but because the process is unforgiving.

This guide will make you claim-ready.

Before documents, before emails, before arguments—what you do immediately after the incident decides the claim outcome.

Do this first (universal checklist)

  1. Intimate the claim quickly (same day if possible).

  2. Don’t repair / dispose / alter evidence before surveyor/TPA instructions (motor/fire especially).

  3. Document everything: photos, videos, timestamps, bills, prescriptions, FIR/DDR if applicable.

  4. Submit documents in one clean batch (avoid “drip-feeding” and delays).

  5. Maintain a single claim folder (physical + drive).

1) Health Insurance Claims

Two routes: Cashless vs Reimbursement

Cashless: Hospital network + pre-authorisation → insurer/TPA pays approved amount directly (you pay non-payables).
Reimbursement: You pay first → submit docs → insurer reimburses admissible amount.

Health claim documents checklist (benchmark: HDFC ERGO)

Always required (most cases):

  • Claim form Part A + hospital form Part B

  • Discharge summary / discharge card

  • Final hospital bill (original) + itemised break-up

  • Payment receipts

  • Pharmacy bills + prescriptions + Consulting papers - chain of consulting paper if someone has referred.

  • Investigation reports (blood tests, imaging, etc.)

  • Implant sticker/invoice (if any implant used)

  • KYC / bank details for NEFT (commonly asked)

Sometimes required (case-based):

  • FIR/MLC in accident cases

  • Treating doctor’s notes / history sheet (especially large claims)

Health claim filing process (simple)

  1. Intimate insurer/TPA (If pre-planned hospitalization: before admission or within hospital timelines; emergency: as soon as stable).

  2. Cashless: Hospital submits pre-auth; insurer/TPA approves fully/partially.

  3. Reimbursement: Collect all originals; submit claim form + documents.

  4. Track claim; respond quickly if insurer requests clarifications.

  5. Don’t forget to make supplementary claim for pre and post expenses based on the 30-day or 60-day criteria.

How settlement is calculated (health)

Approved amount = Eligible expenses – (non-payables + sublimits + co-pay + deductions)

Common health deductions you should expect:

  • Non-medical items (gloves, toiletries, attendants, etc.)

  • Room rent related proportionate deductions (if you choose a higher room category than eligible). Remember, entire claim amount is adjusted based on room-rent.

  • Co-pay (if applicable, often age-based or plan-based)

  • Sub-limits (cataract limits, specific procedures, etc., depending on policy)

Add-ons that reduce pain (policy dependent):

  • Room rent waiver / no sub-limit variants

  • Consumables cover (for health plans that offer it)

  • Restoration benefits (refill sum insured)

Wrong claims people file (and why they get rejected/reduced)

  • “Just add my OPD bills into hospitalisation” → OPD often not covered unless policy says so

  • “I didn’t disclose diabetes because it was minor” → non-disclosure can trigger rejection

  • Cosmetic procedures presented as medical necessity → heavy scrutiny

  • Inflated bills / duplicate bills → fraud flags

2) Car Insurance Claims (Own Damage)

Motor claims are extremely process-driven: intimation → survey → estimate → repair → final bill → settlement.

Car claim documents checklist (benchmark: HDFC ERGO)

Accident (own damage):

  • Claim form

  • Copy of RC

  • Copy of driving licence of the driver at time of accident

  • Repair estimate

  • FIR/police report when required (major accident, third party injury/damage, theft, malicious acts, etc.)

  • Photos of damage (very helpful, often requested)

Theft claim (usually more docs):

  • FIR + final police report/closure report

  • All keys, RC, policy copy, ID proofs

  • Insurer may require additional forms/undertakings

Car claim filing process

  1. Intimate claim immediately (app/website/call). You get a claim number.

  2. Move vehicle to authorised garage (if drivable).

  3. Surveyor inspection (don’t start repairs before survey unless insurer approves).

  4. Garage shares estimate; insurer approves admissible parts/labour.

  5. Repair → final invoice → insurer pays (cashless) or reimburses.

How car claim settlement is calculated

Settlement generally = (Admissible repair cost – depreciation – deductibles – exclusions) ± add-on benefits

Common deductions in motor claims

  • Depreciation on parts (plastic/rubber/fibre etc. depreciate heavily under standard policies)

  • Compulsory deductible (standard amount; many insurers cite ₹1,000 baseline in examples, varies by vehicle/engine)

  • Consumables (unless consumables add-on)

  • Betterment (old part replaced with new increases value)

  • Tyre/tube depreciation (if applicable)

  • Policy excess / voluntary deductible (if chosen)

Add-ons that change the settlement materially

  • Zero Depreciation / Bumper-to-Bumper: reduces depreciation deductions; you typically pay deductibles, insurer bears rest as per wording.

  • Engine protect (water ingression), RTI (return to invoice), consumables cover, roadside assistance (varies)

Wrongful motor claims that get rejected/reduced

  • Driving without valid DL / expired DL (major issue)

  • Drunk driving / racing / intentional damage (exclusions)

  • Repairing before survey approval (common reason for deductions)

  • Claiming old damage as “new accident” (fraud triggers)

3) Fire Insurance Claims (Standard Fire & Special Perils)

This is common for:

  • Homes (fire & perils)

  • Shops, offices, warehouses

  • Factories, plant & machinery

Standard Fire & Special Perils claim form asks core facts (cause, timing, whether fire brigade/police informed, inspection address).

Fire claim documents checklist (benchmark)

Typically required:

  • Claim form (Fire & Allied Perils)

  • Fire brigade report (if fire reported)

  • Police report/FIR (if theft/riot/malicious damage involved)

  • Photographs/videos of damage

  • Stock statement / asset register (commercial claims)

  • Purchase invoices / valuation proofs

  • Repair/replacement estimates + final invoices

  • Surveyor report (insurer appoints surveyor; settlement depends heavily on it)

Fire claim filing process

  1. Ensure safety first, then inform fire brigade/police where applicable.

  2. Intimate insurer immediately.

  3. Prevent further loss (reasonable steps; don’t destroy evidence).

  4. Surveyor visit → you provide records → loss assessed.

  5. Submit invoices/estimates → insurer decides admissible amount.

How fire claim settlement is assessed

Fire claims are usually settled on:

  • Reinstatement/repair cost OR market value, as per policy terms
    Minus:

    • Underinsurance (average clause)

    • Policy excess

    • Salvage value

    • Exclusions

Common fire claim deductions

  • Underinsurance / average clause: if sum insured is lower than actual value, entire claim is proportionately reduced

  • Salvage deducted/adjusted

  • Wear & tear not covered

  • Electrical short-circuit may have specific conditions depending on wording

Add-ons / better structuring that reduces future disputes

  • Correct sum insured and periodic updates

  • Declaration-based stock policies where relevant

  • Add-on covers depending on business risk (Burglar/RSMD etc.)

Wrong fire claims people try (and it backfires)

  • Inflating stock quantity/value without records

  • Claiming old damaged inventory as fire-damaged

  • Not maintaining purchase proofs / stock register → leads to heavy reduction

4) Term Insurance (Death Claim)

This is the one claim where paperwork meets emotion.

Mandatory (most cases):

  • Claim form + NEFT/bank details

  • Death certificate (municipal/government)

  • Policy document (if applicable)

  • Claimant/nominee KYC: ID, address, PAN

Additional (natural death):

  • Medical cause of death certificate

  • Medical records, hospital papers, discharge/death summary (if treated)

Additional (accidental/unnatural):

  • FIR, police inquest report, panchnama

  • Post-mortem report

  • Viscera/chemical analysis where applicable

Term claim process

  1. Intimate claim to insurer.

  2. Submit documents as per death type.

  3. Insurer verifies (and may investigate if needed).

  4. Payout to nominee via bank transfer.

How term claim settlement is decided

  • If policy is active + premiums paid + disclosures were correct → payout is typically straightforward.

  • If there are red flags (non-disclosure, early claim, inconsistencies) → investigation may occur.

Timelines: settlement, delay interest, grievance, ombudsman

Claim decision timeline (core IRDAI standard)

IRDAI requires insurers to settle or reject claims within 30 days of receiving the last necessary document.

If there is delay beyond the stipulated timeline, insurers can be liable to pay interest (IRDAI references interest at 2% above bank rate in applicable cases). (IRDAI)

If your claim is rejected or underpaid: remedy ladder

  1. Ask for a written explanation + calculation sheet + policy clause reference.

  2. Raise grievance with insurer (customer grievance cell).

  3. If unresolved, escalate to IRDAI Bima Bharosa portal / IRDAI complaint channels. (IRDAI)

  4. If still unresolved, approach Insurance Ombudsman (subject to eligibility).

Ombudsman timeline

  • You must first complain to insurer and wait for response (or no response). Ombudsman can be approached within one year of rejection or after no response within stipulated time. (cioins.co.in)

  • Insurer must comply with Ombudsman award within 30 days of receiving it. (Policy Holder)

“Potholes” to avoid while filing claims (the top 10)

  1. Late intimation (especially motor/fire).

  2. Starting repairs before survey (motor/fire).

  3. Missing originals (health reimbursement).

  4. Room category mismatch (health).

  5. Non-disclosure (health history/term proposals).

  6. Illegible/scattered bills (always).

  7. Multiple versions of incident story (motor/fire/term).

  8. No FIR available (theft/major accident/third-party).

  9. Not tracking “last document submitted date” (this starts the IRDAI clock).

  10. Accepting partial settlement without understanding deductions.

Don’t make false claims (and why it harms you long-term)

False claims are not “smart”—they are fraud risk.

Consequences:

  • Claim rejection

  • Policy cancellation

  • Difficulty getting insured in future

  • Legal action in severe cases

  • Higher premiums for everyone (fraud costs get priced into the system)

A clean claim history is an asset. Don’t burn it for a short-term gain.

Final practical tip: Ask for the “claim computation sheet”

Whether it’s health, motor, or fire—if settlement is less than expected, ask for:

  • Deduction reasons

  • Clause references

  • Surveyor remarks (where applicable)

  • Approved vs disallowed line-items

It converts “I feel cheated” into a factual discussion. I have tried and cover most of the pain points in this article. If you wish to discuss any specific points or want us to help you with your insuring needs, do let us know.

Warm regards,

Tejas Lakhani

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