What must a health insurer do after a claim is submitted?

When a claim is submitted, the primary responsibility of a health insurer is to process the claim and notify the insured about the outcome of that process. This involves evaluating the information provided in the claim against the health policy’s terms and conditions to determine if the claim is valid and what amount, if any, is payable to the insured or the healthcare provider.

This process is vital to ensure transparency between the insurer and the insured. It allows the insured to understand the determination made by the insurer, whether the claim was approved, denied, or if further action is required. Timely communication also plays a key role in maintaining trust and ensuring compliance with regulatory requirements that govern insurer obligations after a claim is filed.

In contrast, immediately denying a claim would not follow the required process of evaluating it. Contacting the employer for verification may not always be relevant as the insurer should have sufficient information from the insured's claim submission. Lastly, requesting additional personal information may be necessary in some cases, but it is not a mandatory step to be taken immediately after a claim is submitted, as the insurer should first review the existing information submitted.