Table of Contents
- The One-Line Definition
- A Quick Story to Set the Scene
- How the Adjudication Engine Works (4 Stages)
- Why Your Claim Gets Stuck in “Pending”
- Tempo Matters: Typical Timelines
- Action Plan: 3 Steps to Push Things Forward
- FAQs
(Feel free to jump to the part you need.)
The One-Line Definition
“Pending – Claim Adjudication” means MediBuddy (or the underlying insurer) has received your claim and is now verifying every detail before deciding to pay, adjust, or deny. It’s an in-between checkpoint—not the final verdict.
A Quick Story to Set the Scene
Meet Arjun, a 32-year-old marketing manager who just underwent day-care surgery. He:
- Uploads his bills inside the MediBuddy app.
- Sees the status flip to “Pending – Claim Adjudication” within hours.
- Wonders if that’s good news or trouble brewing.
If you—like Arjun—are staring at the same status, keep reading. By the end of this post you’ll know exactly what’s happening behind the curtain and how to nudge the process along.
How the Adjudication Engine Works (4 Stages)
| Stage | What Happens Behind the Scenes | Possible Outcomes |
|---|---|---|
| 1. Intake & Data Validation | Claim file enters the insurer’s core system; automated bots match policy number, treatment codes (ICD/Procedure) and patient details. | Pass → Stage 2 or Fail → immediate query for missing info |
| 2. Benefit & Policy Check | System cross-checks coverage limits, sub-limits, waiting periods, & pre-authorization tags. | Approved for payment, flag for medical review, or partial coverage note |
| 3. Medical Necessity Review | Human adjudicator examines charts, prescriptions & rationale for expensive/experimental care. | Approve, reduce amount, ask for clarifications |
| 4. Payment Drafting | If cleared, payment advice is generated; else a denial letter with reasons. | Status moves to Approved / Partially Approved / Rejected |
Why four steps? Because insurers must comply with IRDAI guidelines and internal audit trails before releasing funds.
Why Your Claim Gets Stuck in “Pending”
- Missing documents – e.g., pre-op lab reports or a signed discharge summary.
- Coding mismatch – procedure code on the bill doesn’t align with what your policy covers.
- Policy questions – waiting-period clauses, sub-limit breaches, or pre-existing condition gaps.
- High-value red flag – claims above a certain rupee threshold undergo extra human scrutiny.
Tempo Matters: Typical Timelines
Usual range: 7–14 working days from “Pending” to final status (assuming no queries).
Complex surgeries, foreign bills, or repeated follow-ups from the insurer can stretch that to 20+ days.
Action Plan: 3 Steps to Push Things Forward
- Mark Day 10 on your calendar. If the status is unchanged by then, it’s time to act.
- Call or raise a ticket in MediBuddy with your claim ID. Ask exactly which document or code is holding things up.
- Upload the missing paperwork within 48 hours—use PDF scans (clear, under 2 MB each) and mention your claim ID in the file name.
Pro-tip: Keep every WhatsApp hospital conversation and e-mailed estimate—they can quickly prove medical necessity if questioned.
FAQs
Q1. Does “Pending – Claim Adjudication” mean my claim is approved?
Not yet. It simply means the decision is in progress.
Q2. Can I still add documents at this stage?
Yes, and you should if the insurer raises a query.
Q3. The status just flipped to “Query Raised.” What’s next?
Provide the requested info ASAP; the clock restarts only after they receive it.
Final Word
Think of “Pending – Claim Adjudication” as the security check at the airport: necessary, usually quick, but occasionally slow if something in your bag looks odd. Prepare your paperwork, stay responsive, and your claim should sail through.
Have more questions? Drop them below or reach out—happy to help you decode insurance jargon in plain English!