What is an Insurance Claim?

An insurance claim is a formal request submitted to an insurance company by a policyholder to receive payment for a loss covered under their insurance policy. Once a claim is filed, the insurer is required to investigate and make a coverage decision within timeframes specified by state law (typically 15–30 days for acknowledgment, 30–45 days for decision).

• The loss: A physical event that causes damage (fire, wind, water, collision, etc.)
• Coverage trigger: The loss must fall under a covered peril in your policy
• Proof of loss: Documentation showing what was damaged and why (photos, estimates, receipts)
• Formal notification: Written communication to the carrier reporting the loss

1. Claim Reported: You report the loss to your insurance company, typically by phone or online.
2. Investigation: Adjuster investigates the cause of loss and determines if it's covered.
3. Inspection: Adjuster inspects the property and documents damage.
4. Estimate: Adjuster creates an estimate for repair/replacement costs (the scope of loss).
5. Coverage Decision: Insurer decides whether to approve, deny, or partially approve the claim.
6. Payment: If approved, insurer issues payment based on the scope of loss and applicable deductible.

• Approved: The loss is covered and full payment is issued.
• Denied: The insurer determines the loss is not covered under the policy.
• Partially Approved: Some items are covered while others are excluded or denied.
• Pending: The claim remains open pending additional investigation or documentation.

• Right to timely response from the carrier
• Right to written explanation for any denial
• Right to request reconsideration or supplement for missing items
• Right to file a complaint with your state Department of Insurance
• Right to hire a public adjuster or attorney to represent you