An insurance claim is the actual application for benefits provided by an insurance company. Policy holders must first file an insurance 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 their 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 insurance claim or to build up the available assets of the insurance company. But occasionally an accident will happen which causes real financial damage, such as a automobile wreck or 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 insurance claim and negotiating the payment from the main insurers. Many times a recognized authority (doctor, repair shop, building contractor) can file the necessary insurance claim forms directly with the insurance company. However, sometimes the policy holder may not want to file an actual insurance claim if the damage is minor or another party has agreed to pay out-of-pocket for their mistake.
After an insurance claim is filed, the insurance company may send out an investigator called an adjustor or appraiser. The insurance adjustor's job is to objectively evaluate the insurance claim 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 on the insurance claim.
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 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 an insurance claim may be rejected is a failure to fall under covered conditions. Most insurance policies spell out specific areas which qualify for benefits. 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.
An insurance 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.