Filing and Paying Claims

Starting the Claim: Notice of Claim and Claim Forms

When a covered loss occurs, the claim process begins with specific communication steps. The National Association of Insurance Commissioners (NAIC) Uniform Individual Accident and Sickness Policy Provisions Law establishes standard mandatory claims provisions that govern these steps. Under the NAIC model notice of claim provision, written notice must be given to the insurer within 20 days after a covered loss occurs or begins, or as soon afterward as reasonably possible; the insured, a beneficiary, or someone acting on their behalf may give notice. Late notice of claim may delay a claim or, depending on the circumstances and applicable law, result in denial.

The insured, a beneficiary, or someone acting on their behalf may give written notice of claim. It must be sent either to the insurer or to any authorized agent of the insurer, and it must include sufficient information to identify the insured person. For an ongoing disability claim, a policy may require written notice that the disability continues. However, the NAIC model does not permit requiring that continuing disability notice more often than every six months.

Once the insurer receives this notice, the claim forms provision takes effect. The insurer is required to furnish claim forms to the claimant within 15 days of receiving the notice of claim. If the insurer fails to provide the forms within that 15-day window, you do not have to wait. You can meet the proof of loss requirement by submitting written proof within the required time without using the insurer's forms, provided the written documentation describes the occurrence, character, and extent of the loss.