Merritt Personal Lines Manual: Notifying the Insurance Company of a Claim
Notice of Claim: Written notice of claim must be given to us within 20 days after the occurrence of any covered loss, or as soon as reasonably possible. Notice given by or on behalf of the insured person to us at our Home Office, or to any of our authorized agents, with information sufficient to identify you or the insured person shall be considered as notice to us.
You should give written notice of a claim within 20 days after any covered loss, or as soon as reasonably possible. Extra time is granted if, for example, you're seriously injured and notice cannot be given within the listed time period. Notice may be given directly to the insurance company or to an agent.
Claim Forms: Upon receipt of a notice of claim, we will furnish forms to the claimant for filing proof of the loss. If we do not furnish the forms within 15 days after we have been given the notice, we will consider the claimant to have complied with the requirements for filing proof of loss, provided we have received, within the time fixed in the policy for filing proof of loss, written proof of the occurrence, the character and the extent of the loss for which the claim is made.
When the insurance company receives notice of a claim, it will usually furnish claim forms within 15 days. If it fails to do so, you may comply with the requirement for filing proof of loss by submitting written proof of the occurrence, character and extent of the loss. This can be in the form of an official accident report form or simply a affidavit that you've signed.
Proof of Loss: We must be furnished written proof of loss within 90 days after the date of loss. We will not reject or reduce any claim because we are not furnished proof in the time required if it is not possible for you to do so. However, proof must be furnished as soon as reasonably possible and in no event, later than one year from the time proof is required, unless it is legally impossible to do so.
Formal proof of loss (on company claim forms) should be submitted within 90 days after any covered loss. Once again, extra time is granted if it's not possible for you to respond within this time period. But proof must be furnished as soon as reasonably possible and no later than one year from the time proof is otherwise required (unless you're legally incapacitated at that point).
Issues of incapacitation are less important here than simple forgetfulness and inaccuracy. Most disputes over proof of loss reports involve situations in which policyholders only include some of the expenses they've accrued in their reports. Then, when the insurance company only covers some of the bills, accusations start to fly.
A caveat: Insurance companies won't cover costs they can't verify on the proof of loss form. Make sure you include everything. Most doctors offices and hospitals will help you out in this effort.
Time of Payment of Claim: Any benefits payable under this policy will be paid immediately upon our receiving written proof of the loss.
Policyholders will often refer to this paragraph when they're suing their insurance company for breach of contract. When faced with this kind of claim, the insurance company will usually refer to the paragraph dealing with proof of loss--and argue that the policyholder didn't supply that completely or on time.
Payment of Claims: Any benefits are payable to you. Any accrued benefits unpaid in the event of your death may, at our option, be paid to your estate. If any benefit is payable to your estate, or to an insured person who is a minor or otherwise not competent to give a valid release, we may pay such benefits (up to amount not exceeding $1,000) to any relative by blood or connection by marriage of yours who we consider to be equitably entitled. Any payment made by us in good faith in accordance with this provision will fully discharge us to the extent of the payment.
Benefits are payable directly to yo -- generally, medical insurance policies provide reimbursement for covered expenses. This means the insurance company wants you to pay your medical bills first--and then it will pay you. Traditional insurance companies would rather not get involved directly with doctors or hospitals.
In the event of your death, benefits may be paid to your estate.
Whenever benefits are payable to an insured's estate or to an insured who cannot give a valid release (a person who is a minor or incapacitated), the insurance company has the option of paying benefits of up to $1,000 to a relative who appears to be entitled to receive the funds. This may occur if a relative has been caring for the insured and handling financial matters.
