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What is an Insurance Claim?

Michael Pollick
By
Updated May 17, 2024
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An insurance claim is the actual application for benefits provided by an insurance company. Policy holders must first file a claim before any money can be disbursed to the hospital or repair shop or other contracted service. The insurance company may or may not approve the claim, based on its own assessment of the circumstances.

Individuals who take out home, life, health, or automobile insurance policies must maintain regular payments called premiums to the insurers. Most of the time, these premiums are used to settle another person's claim or to build up the available assets of the insurance company. Occasionally, however, an accident will happen that causes real financial damage, such as a automobile wreck, a tornado, or a work-related accident. At this point, the injured policy holder has the right to file an insurance claim in order to receive money from the insurance company.

In general, the insurance claim is filed with a local representative of the insurance company. This agent becomes responsible for investigating the specific details of the claim and negotiating the payment from the main insurers. Many times, a recognized authority — like a medical professional, repair shop, or building contractor — can file the necessary forms directly with the insurance company. The policy holder may not want to file if the damage is minor or another party has agreed to pay out-of-pocket for their mistake, however.

After a claim is filed, the insurance company may send out an investigator called an adjustor or appraiser. This person's job is to objectively evaluate the damage and determine if the repair estimates are reasonable. This is to prevent possible fraud by contractors who may inflate their bills for additional compensation. Insurance companies tend to accept the adjustor or appraiser's evaluation as the final word.

Some insurance claims may not be recognized by the insurance company for any number of reasons. If a claimant's premiums have not been paid in full, the policy itself may not be active. Another insurance company may also have already agreed to pay for the damages listed in the claim. This happens quite often in automobile accidents where one party is held responsible.

Another reason that a claim may be rejected is a failure to fall under covered conditions. Most insurance policies spell out specific areas which qualify for benefits, and if the accident or damage claim was caused by carelessness or an unavoidable "Act of God," the insurance company has the right to withhold payments. A claim is the only way to officially apply for benefits under an insurance policy, but until the insurance company has assessed the situation, it will remain only a claim, not a pay-out.

WiseGEEK is dedicated to providing accurate and trustworthy information. We carefully select reputable sources and employ a rigorous fact-checking process to maintain the highest standards. To learn more about our commitment to accuracy, read our editorial process.
Michael Pollick
By Michael Pollick , Writer
As a frequent contributor to WiseGEEK, Michael Pollick uses his passion for research and writing to cover a wide range of topics. His curiosity drives him to study subjects in-depth, resulting in informative and engaging articles. Prior to becoming a professional writer, Michael honed his skills as an English tutor, poet, voice-over artist, and DJ.

Discussion Comments

By anon352545 — On Oct 23, 2013

Do you know if our insurance pays for crutches? I don’t think so but thought I’d check.

By anon348471 — On Sep 17, 2013

This may be different. What does a life insurance claim mean if it went through payment? I've been waiting six months in order to receive a death benefit, so I can bury my partner.

By swart — On Aug 24, 2013

I have a big problem. My four month old car was destroyed by a flood. I have reported it to my insurance company and car dealer, and they said that I have to wait for three days to assess the damage. I don't have any idea on how long it could take to solve, or do I really have to pay for some expenses?

By anon291680 — On Sep 15, 2012

Can anybody help? I was in my first auto accident. Someone ran right in the back of my car as I was stopped at a red light. I then got in touch with his insurance company,they took the claim an said they'd call me back. They finally called back and told me my "insurance claim was approved." Does that mean they're going to pay for my car?

By anon264531 — On Apr 28, 2012

Wow. Lots of post here about issues people continue to have with insurance companies. Keep this in mind, "Your insurance policy protects you!" You don't need a lawyer or public adjuster to fight an insurance claim dispute with your carrier.

There is a clause in your policy known as appraisal. In summary, an independent appraiser represents you and another appraiser represents your insurance company. The two appraisers then get your claim settled. It worked on my fire claim dispute against State Farm. My appraiser helped tremendously.

Good luck and don't give up!

By anon129112 — On Nov 22, 2010

I have a 19 year old who does not have his own car and is not allowed as a freshman to drive to college. However, we did allow him to take our car to take some stuff up to the college and a man ran him off the road. He had his seatbelt on and was running the speed limit but our car is totalled and we only had liability on it.

Will my insurance go up if we turn in just for him to be checked out at the hospital? He still will not be driving to school or have a car at this time.

By anon125905 — On Nov 10, 2010

The value obtained by hiring a Public Adjuster cannot be compared. They truly level the playing field and the increase that they get you for damages far exceeds the value of their fee. I don't know who is charging 30 percent, but that is not legal. The fees are usually 15 to 20 percent.

By anon101266 — On Aug 02, 2010

Anyone have any idea why searches for "insurance claims" have been steadily rising online? We're trying to figure it out. Thanks.

By anon84152 — On May 13, 2010

My wife Sheelah fell in the lobby at a restaurant due to grease on the floor left by a shoddy mop job by their employee.

We've paid $300 cash (out of pocket) so far to a clinic, but her medical bills have only started. The insurance investigator declared that the restaurant was liable for the fall and has allowed a maximum payout of $5,000.00 (max)for medical expenses providing we give them the bills.

This is becoming a burden on our pocket book since we cannot afford medical insurance and I have been laid off from my job since January. We will have to skip meals to pay the medical bills.

What about the pain and suffering she has to endure? Seems they get off for paying her for that and how would you calculate that anyway? This insurance system stinks big time! What are our options at this point? Terry

By anon59004 — On Jan 05, 2010

In Texas I filed a insurance claim after ike. then they refused to renew my policy. I hired a lawyer after several months they said my case was in appraisal, six months later i still did not hear anything from my lawyer. I fired them. Then they sent me a letter that said they would not represent me anymore. Then they said i was trying to collect on 2005 damages. Not true. They think i will just go away --not so Slavonic insurance company in Texas.

Don't give up on a insurance claim; that is what they want you to do. Fight them till you get what you want.

By anon54459 — On Nov 30, 2009

Thanks for such a great post. I really felt well-educated after reading it.

Hurricanes are scary. I'm so happy that this year we did not have any huge hurricanes.

Being a business owner, it gets really hard to have the correct insurance plan and also be well prepared for a hurricane.

In the past I have used Adjusters International, to help me deal with insurance agencies. And they have made my work so much easier.

Now, I'm not too scared about the hurricane season. I'm not trying to market here, but i really understand the concerns of other business and home owners.

Thanks again. :)

By sandyd0602 — On Aug 04, 2008

For any homeowner out there.. you might be able to relate to this! I live in Miami, and after Hurricane Wilma a few years back, my home insurance company refused to entitle me to any monies because my deductible was 'too high.' I thought about hiring a public adjuster, but I'd end up giving almost 30% of my settlement with my insurance company to them.

A friend of mine then told me about a new website that enables you to work as your own adjuster, and is designed to maximize your insurance payout, which is exactly what it did for me. I'm currently settling with my insurance company for almost three times the amount I was initially going to receive.

By k1sstheglock — On Jul 27, 2008

Thanks a lot!!!

By frankjoseph — On Jul 23, 2008

K1sstheglock - In California, you are legally obligated to report traffic accidents that result in at least $500 in damage. If the police came and documented the accident, then you could see if that information was included on the police report. Otherwise, you can not compel someone to produce their insurance information unless you bring a lawsuit against that person. But if you report the accident to your insurance company, then they will do all the legwork for you. It is my understanding, that an insurance company is not allowed to raise your insurance payments if you were involved in an accident that was not your fault. So, if you were not at fault, your best bet is to just report it to your insurance company and let them take care of the rest. That service is, in part, what you are paying your premiums for!

By k1sstheglock — On Jul 23, 2008

In an automobile accident, if an insurance provider is not given at the time of the accident and the driver at fault does not pay out of pocket to fix the car, how might one find the insurance provider of the driver at fault to file a claim with their insurance? Or, is there a way to find their insurance provider through the police or through my own insurance company without filing a claim with my insurance company?

Michael Pollick

Michael Pollick

Writer

As a frequent contributor to WiseGEEK, Michael Pollick uses his passion for research and writing to cover a wide range...
Learn more
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