The Advisor's Role in a Retail Claim: What Clients Expect and What You Owe

A retail claim starts with a phone call, and it almost never starts with the insurer. The car is on the side of a highway, or a parent has been admitted overnight, and the number that gets dialled is the advisor saved in the phone under a first name. Nobody in that moment is looking up a toll-free line or a claims portal. They are calling the person who sold them the policy, because that is the only human being attached to the contract in their mind.

That is the whole asymmetry of the job. You are the first call and, if the claim goes badly, the first person blamed. You are also the person with the least formal standing in the entire process. You do not decide the claim. You do not assess it. You do not pay it. Your name is not on the settlement letter. Nothing in your engagement gives you authority over any part of the outcome.

Most advisors handle the gap by pretending it is not there. They talk as though they have influence they do not have, then go quiet when the file stalls. That sequence, confident at intimation and unreachable at repudiation, is the most reliable way to lose a household permanently.

The alternative is to scope the role honestly, out loud, before it is tested. There is a real job here. It is smaller than clients assume and larger than the paperwork suggests, and getting the boundary right is what lets you be useful during a claim instead of merely present.

You do not adjudicate

The claim is decided by the insurer, and on a health claim usually by a third-party administrator acting under the insurer's authority, against the policy wording, by people who never met your client. You can put information into that process. You cannot weight it. An advisor who says "I will get this passed" has described a power that exists nowhere in the arrangement.

You do not represent the insurer in the claim

This one surprises advisors as often as clients. A POSP is tied to a single principal, an insurer or an intermediary, and that tie is a solicitation relationship. It authorises you to source and place business carrying your POS Code. It does not deputise you into the claims function. The claims department is not your department, its decisions are not made in your name, and they are not yours to communicate as though they were.

You have no authority over the outcome

You cannot waive an exclusion. You cannot bring forward the expiry of a waiting period. You cannot approve a shortfall or overrule a deduction. Every one of those sits with the insurer, and several of them sit with the wording rather than with any human being at all.

The first hour of a claim is the part you can genuinely affect, and it is the part where wrong advice does permanent damage. Almost everything else in a claim can be corrected later. An intimation made late, wrongly, or to a desk that never logged it often cannot be.

Accurate intimation guidance is narrow and specific:

• Intimate now, not once the paperwork is ready. Clients delay because they are assembling documents. Intimation and documentation are separate events and the first does not wait on the second. A claim intimated on the day of loss with nothing attached is in far better shape than a complete file submitted three weeks later.
• Name the desk. The insurer's claims line, the TPA number printed on the health card, a network garage's cashless counter, the insurer's app. These are not interchangeable, and a client who tells you they "informed someone" has usually informed nobody who logged it.
• Say what not to do. Do not authorise repairs before the claim is registered. Do not settle privately with the other driver at an accident scene and then file. Do not pay cash at discharge because the wait was long and expect a clean reimbursement afterwards.
• Get the claim reference number and write it down against the client. A claim without a number is a claim nobody can trace, including you.

Read the intimation timeline from the client's own policy rather than from memory. Wordings differ between insurers on the same product, and the number in your head is probably from a different policy sold to a different household. The duty to run a fair and timely claims process sits on the insurer under the IRDAI (Protection of Policyholders' Interests, Operations and Allied Matters of Insurers) Regulations, 2024. The clock the client has to meet is in the client's own document. Being right here costs you nothing and is worth more than everything else you do in the claim combined.

The second thing you owe is the policy document produced within a minute of being asked, not within an afternoon.

This sounds trivial. It is the most common way advisors fail a claiming client. The call comes at eleven at night from a hospital admission desk asking for the policy number and the insurer's name, and the advisor is scrolling a chat thread from fourteen months ago hunting a PDF that may have been cleared when the phone filled up. The client is standing at a counter while this happens. The delay is the failure.

What has to come up, by client name, in under a minute:

1. The current policy schedule, not the one from two renewals ago.
2. The policy number and the insurer's name, spelled the way the insurer spells it.
3. The period of insurance, so you know without checking whether the loss date falls inside it.
4. The sum insured and the exact plan variant.
5. The health card number or the TPA's name, where one applies.

This is where filing discipline stops being administrative hygiene and becomes something the client experiences directly. Every hour spent naming files properly is refunded in this one call. Every shortcut is charged to you in it.

The third duty is the least comfortable and the most valuable: an honest reading of what the wording will do with this specific loss, delivered before the insurer delivers it.

You know the policy. You know that a room-rent sub-limit is about to produce a proportionate deduction on a room the family has already chosen. You know a waiting period has not run. You know consumables are not payable and the discharge bill will carry a line for them anyway. The client knows none of it, and will find out at the payment counter unless you say it at admission.

The temptation is to stay quiet. Silence feels neutral. It is not. Silence transfers the whole shock to the moment of payment, where it lands as a surprise from you rather than as information from you.

The honest version sounds like this: the policy will respond, here is what it will not pay, and here is roughly what you should be ready for. It is a worse conversation than optimism and a much better one than the conversation you will otherwise have at discharge.

Be honest in the other direction too. Plenty of claims a client has written off are payable. A household that has decided the claim will be rejected often does not file it at all. Telling someone their claim is worth making is the same duty as telling them it is not.

The fourth duty separates advisors from each other, because it is invisible while it is happening and obvious only when it is missing. Follow-through means the claim stays on your list until it closes, not until it stops feeling urgent.

Most claims do not fail at intimation. They stall in the middle: a query nobody answered, a document nobody re-sent, a discharge summary sitting in a hospital's records room. The insurer is waiting, the client does not know the file has stopped moving, eleven days pass, and then the client calls you angry.

What follow-through actually is:

• A list. Every open claim in the book, with the claim number, the date intimated, the last thing that happened and the next thing that has to. If it lives only in your head, it is not a list, and you will drop the third one.
• A cadence. Look at the open claims on a fixed day rather than when you happen to remember. A stalled file surfaces because you looked, never because somebody told you.
• A call even when there is nothing to report. "Still with the insurer, no query raised, I checked today" is a complete and useful update. Advisors go quiet in dead air because they feel they have nothing to say, and the household reads the silence as abandonment.
• A written note of what you were told. Who you spoke to, when, and what they said. On a contested claim that is the difference between a position and a memory.

None of this requires authority. All of it is available to someone with no standing whatsoever. Which is exactly why it is the part of the job that is genuinely yours.

Never promise an outcome

"Don't worry, this will get passed." It is the most natural sentence in the world to say to a frightened person at midnight, and it is the one sentence that guarantees the relationship ends badly. You do not decide the claim. Promising an outcome you do not control converts the insurer's decision into your broken word. When the deduction lands, the household is not disappointed with the insurer. They are betrayed by you.

The substitute is not coldness. It is precision. "I will get this intimated tonight and I will stay on it" is a promise about your own conduct, which you can keep. "This will be approved" is a promise about someone else's, which you cannot.

Never paper over an exclusion you should have explained at sale

This is the one that ends advisors quietly. The claim fails on a waiting period, a sub-limit, a condition that was never declared. The client asks why nobody told them. And the advisor, who did not tell them, starts explaining that the insurer is being unreasonable.

That move is worse than the original omission. It is a second failure stacked on the first, it is visible to the principal whose code carried the proposal, and it does not work. The wording gets read out eventually, by the TPA, by the grievance desk, or by the Insurance Ombudsman if it goes that far, and it says what it always said.

If a claim is failing on something you never explained at sale, the honest move is to say so. It is a painful conversation and a survivable one. The alternative is a household that tells everyone it knows that their advisor sold them something and then blamed the company for it.

Step back from any individual claim and a pattern appears that is uncomfortable for the whole channel. The disputes that go badly are rarely claims problems. They are sale problems that took eighteen months to surface. A room-rent sub-limit nobody mentioned because mentioning it spoiled the premium comparison. A pre-existing condition left off the proposal because declaring it meant a loading or a rejection, and the form went in more smoothly without it. A cheap plan variant sold as though it were the variant above it. Every one of those closes fine. Every one detonates at the first claim, which is precisely when the household is least able to absorb it.

The doctrine of utmost good faith runs both ways in principle. In practice it bites the policyholder hardest at claim stage, because non-disclosure is the cleanest ground an insurer has for repudiation. The person sitting beside the client while the proposal was filled, who knew what was said in the room and what did not make it onto the form, was the advisor. That is why a repudiation for non-disclosure is so often, underneath it, an advisor's own file being read back to them.

The implication is operational rather than moral. The way to be good at retail claims is to be honest at the point of sale, because the claim is where the sale gets audited. Every exclusion explained at proposal is a claim that never becomes a dispute. Every uncomfortable sentence dodged at sale is a call you take at a hospital counter instead, with less time and worse odds.

Your role in a claim is small, informal and real. You do not adjudicate it, you do not represent the insurer in it, and you control nothing about the result. What you control is whether the intimation was right, whether the document was there, whether the client knew what was coming, and whether the file kept moving. Those four are enough to be the reason a claim went well, and their absence is usually the reason one went badly.