Claimant
A claimant is the person or organization asking an insurer to pay a covered loss or benefit. That can be the policyholder, an insured, someone injured by an insured, a beneficiary, a healthcare provider or an authorized representative. Being the claimant does not guarantee coverage or payment; the policy, evidence, limits, deductibles and state law decide that.
Also called: CLMT, first-party claimant, third-party claimant
When a claim letter, proof-of-loss form or explanation of benefits says "claimant," it names who is asking for payment, nothing more. The label does not settle whether the loss is covered, how much will be paid or who receives the check. Those answers come from the coverage that responds, its limit and deductible, the claim deadlines and the state rules that apply.
How a claimant's payment is worked out
A claim is "a request or demand for payment of a loss that may be included within the terms of coverage of an insurance policy," according to the NAIC homeowner data call definitions (opens in a new tab). The claimant is whoever makes or pursues that request, and the policy limit caps what the insurer pays, whatever amount the claimant asks for.
The example below uses Connecticut's minimum bodily-injury limit of $25,000 per person, published by the Connecticut Insurance Department (opens in a new tab). The $60,000 in damages is illustrative, not an average or a settlement prediction.
Hover or tap a row to highlight it.
| Step | Amount |
|---|---|
| Covered damages to the injured person | $60,000 |
| Driver's bodily-injury limit per person | $25,000 |
| Most the liability coverage pays this claimant | $25,000 |
| Amount not paid by that limit ($60,000 minus $25,000) | $35,000 |
The injured person may pursue the $35,000 balance against the legally responsible driver, subject to liability, collectability, other coverage and court results. On a first-party property claim, the deductible comes off instead: an illustrative $10,000 covered loss with a $500 deductible pays $9,500.
Types of claimant and what each changes
Who you are in the claim changes which policy you claim under and who gets paid.
- First-party claimant. You claim under your own policy, such as collision, comprehensive, health or personal injury protection. Payment may come to you or go to a repair shop or provider.
- Third-party claimant. You claim against someone else's liability coverage after they cause a loss. You are the claimant, and the person who caused the loss is the insured.
- Beneficiary. A person named to receive life insurance or another benefit can become the claimant after the insured's death.
- Provider or representative. A healthcare provider or authorized representative may submit or pursue a claim in appropriate circumstances, under the claimant definition in CMS reporting guidance (opens in a new tab).
The claimant and the payee can differ. A health explanation of benefits can show payment going to a provider, per CMS (opens in a new tab), and a lienholder, repair facility or assignee may be paid on other claims. Calling an insurer "for information only" is not necessarily a claim; the NAIC definitions exclude information-only reports where no claim was opened for payment.
Where the word appears
You see "claimant" on auto liability, medical payments, PIP, uninsured and underinsured motorist, collision and comprehensive claims; on homeowners, condo, renters, flood and commercial property claims; and on health, disability, long-term-care, life, workers' compensation, pet and business liability claims. It shows up on claim forms, proof-of-loss forms, acknowledgments, reservation-of-rights letters, denials, settlement releases, arbitration papers, explanations of benefits and appeal forms.
Quotes and declarations pages rarely use it, since they list the named insured, limits, deductibles and premium. A standard homeowners form does not define "claimant" at all; its claim conditions refer to "you" or "an insured seeking coverage," per the ISO HO-3 sample form (opens in a new tab). A lender or landlord usually wants proof of insurance, not claimant status. For the steps after a crash, see how to file a car insurance claim.
What Connecticut and New York require of insurers
In Connecticut, an insurer that, as a general business practice, fails to acknowledge claim communications promptly, investigate reasonably, or settle promptly and fairly when liability is reasonably clear commits an unfair claim practice under Conn. Gen. Stat. § 38a-816 (opens in a new tab). For certain disputed auto physical-damage claims, Bulletin CL-5 (opens in a new tab) describes an arbitration process in which a failure to respond to the notice within 14 calendar days may allow an award for the claimant, payable within 10 business days.
New York requires insurers to tell a claimant whether a claim is accepted or denied within 30 working days after a properly executed proof of loss, under N.Y. Insurance Law § 2601 (opens in a new tab). No-fault benefits are overdue if unpaid 30 days after the claimant proves the fact and amount of loss, and overdue amounts bear 2% monthly interest, under N.Y. Insurance Law § 5106 (opens in a new tab). New York's basic no-fault coverage pays up to $50,000 per person in basic economic loss, according to New York DFS (opens in a new tab).
Questions to ask an agent or insurer
- Am I the claimant, the insured, the policyholder, the beneficiary or more than one of these? The label affects who submits documents, receives notices and gets paid.
- Which coverage is responding, and what limit, deductible, exclusion or waiting period applies? Claimant status does not establish coverage or the amount payable.
- Will payment go to me, a provider, a lienholder, a beneficiary or another payee? The claimant and payee can be different.
- What notice, proof-of-loss, examination or appeal deadline applies? State law and policy conditions set different time limits.
- Could this claim affect my renewal or premium, and which rating factor applies? Claims history is one factor that can affect auto premiums in Connecticut, according to the Connecticut Insurance Department (opens in a new tab).
Frequently asked questions
These questions come up most once a claim is open.
Is a claimant the same as an insured?
No. An insured is protected by the policy, while a claimant is whoever seeks payment. An insured can be a claimant, and so can an injured third party who is not an insured under that policy.
Does being listed on a policy make me a claimant?
No. Being listed as a driver, household member, certificate holder or additional interest does not make you a claimant, or an insured for every coverage.
Can a claimant appeal a denied health claim?
Generally, yes. Internal appeals usually must be filed within 180 days of the denial notice, and external-review requests within four months, according to HealthCare.gov (opens in a new tab). In Connecticut, an external-review request is generally due within 120 days after internal review ends, per the Connecticut Insurance Department (opens in a new tab).
Does an appraisal change who the claimant is?
No. Appraisal resolves the amount of property damage when coverage is not necessarily disputed, and the claimant stays the same, as the Connecticut Insurance Department (opens in a new tab) describes.