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Claim

A claim is a demand by an insured to recover damages under an insurance policy. A claim is not the same thing as a loss. The insured or a third party makes a claim and the insurance company’s adjuster determines if the claim is valid and the amount of the claim. Once the insurance company agrees the claim is valid, it becomes a loss.For example, a person may claim that he or she was bitten by the neighbor’s dog and request reimbursement for medical expenses related to the bite from the neighbor’s homeowners insurance company. After investigation it is found that this is not the case. Thus, a claim was made, but there was no loss. (See Loss).
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UK: A demand by the insured for an indemnity or benefit under the policy. The claim will be met, subject to any limits, if the loss event is caused by an insured peril and is not excluded.
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REINSURANCE: A demand made by an insurer on its reinsurer(s) to be paid under a reinsurance contract. A claim is payable under an insurance or reinsurance contract if it is caused by an insured peril and it is not excluded under the terms of that contract.
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A request for disbursement of the benefits promised in the contract.
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US: A request for payment of a loss which may come under the terms of an insurance contract.
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Depending on the context this term may refer to (01) A demand by the insured for payment under his Policy. Claim covers loss caused by perils insured against. The insured is entitled to lodge the claim and recover the loss from Insurance Company. Claim is a demand for payment under an Insurance contract or bond. (02) Estimated or actual amount demanded. (03) A demand made by a third party on a policyholder to be compensated for some injury, damage or loss for which the third party blames the policyholder. In this case, claims are referred to the insurer to handle on behalf of the insured in accordance with the term of the Policy. (04) A demand made by an insurer on its reinsurer(s) to be paid under a reinsurance contract. A claim is payable under an insurance or reinsurance contract if it is caused by an insured peril and it is not excluded under the terms of that contract.
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Depending on the context this term may refer to: (a) a demand made by a policyholder on his insurer(s) for payment or some other contractual benefit under an insurance policy; (b) a demand made by an insurer on its reinsurer(s) to be paid under a reinsurance contract; or (c) a demand made by a third party on a policyholder to be compensated for some injury, damage or loss for which the third party blames the policyholder. A claim is payable under an insurance or reinsurance contract if it is caused by an insured peril and it is not excluded under the terms of that contract.
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MEDICAL,USA: Formal request for payment (bill) sent to an insurance carrier or fiscal intermediary for a private insurance program, managed care plan, or a government program for medical services rendered to insureds or beneficiaries; also called insurance claim.
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UK: invocation of a right to a payment under a contract of insurance; also the amount set aside in the accounts of an insurers respect of payments made or anticipated.
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Notice to an insurer that under the terms of a policy, a loss maybe covered.
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US: Used in reference to insurance, a claim may be a demand by an individual or corporation to recover, under a policy of insurance, for loss that may come within that policy.

Claim adjustment reason codes

National administrative code set that identifies the reasons for any differences, or adjustments, between the original provider charge for a claim or service and the payer’s payment for it. This code set is used in the X12 835 claim payment and remittance advice and the X12 837 claim transactions and is maintained by the Health Care Code Maintenance Committee.

Claim agent

An agent of the insurance company who has the power to pay the insured for a loss.
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The Agent appointed by an Insurer to settle the Marine Overseas losses as per prevailing guidelines.

Claim attachment

Document with information, hard copy or electronic, related to a completed insurance claim that assists in validating the medical necessity or explains the medical service or procedure (e.g., operative report, discharge summary, invoice). When a claim attachment is included with a paper claim, Block 19 of the CMA-1500 insurance claim form is completed. When a claim is electronically transmitted, practice management and claims software include a data field that indicates that a paper claims attachment is included with the claim. Under the Health Insurance Portability and Accountability Act (HIPAA), electronic standards for claims attachments are being developed. Attachments may be structured (such as Certificates of Medical Necessity) or nonstructured (such as an operative report). Though attachments may be submitted separately, it is common to say the attachment was “submitted with the claim.”