Reasons for Health Insurance Claim Rejection

Some of the most common reasons for rejection of a claim include non-submission of the necessary supporting documents or including incorrect information on the claim form. Your health insurance claim may also be rejected for non-disclosure of medical history like pre-existing conditions or because of a failure to intimate the insurer on time.

When a health insurance claim is filed with an insurance provider, all aspects of the claim are thoroughly investigated by the insurer. And only when the insurer is satisfied is the claim amount disbursed. However, an insurance provider may choose to reject an insurance claim for any of the reasons mentioned above. 

Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024. The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918

Health Insurance Rejection: What are the Reasons?

A particular insurance claim may get rejected based on various factors.  Here are the main reasons behind health insurance claim rejections you should be aware of:

 

• Exclusions: Most health insurance policies have a list of exclusions. Exclusions refer to diseases or illnesses or self-inflicted damages, among others, which are not covered by the insurance company. If you try to claim coverage for one of the conditions mentioned in your insurance company’s exclusion list, your claim request will get rejected.

• Hospital Bills: If your insurance policy has a reimbursement form of repayment, you need to make sure that you keep all the original receipts and copies of all the hospital bills and other related medical expenses. If you do not have the original bills during the time of settlement of the claim, your insurance claim may get rejected.

• Hiding Medical History: If you do not disclose your pre-existing diseases/medical conditions or any history of medical illness at the time of buying medical insurance, your claim may get rejected, as insurance companies calculate their risks based on a person’s pre-existing conditions and medical history.

• Lapsed Policy: If you fail to pay your health insurance premiums, your policy may lapse. If you try to make insurance claims on your lapsed policy, there is a very high chance your claim may get rejected outright.

• Inform the Insurance Company on Time: When you buy health insurance online, read all policy-related documents. There will be a specified time at which you can submit the insurance claim for your medical expenses. Once the specified time for submitting the insurance claim has passed, your insurance claim might get rejected. Different insurance companies will have different periods for the submission of claims.

• Submitting Incorrect Information: If you submit incorrect documents and information at the time of filing your insurance claim, your claim may get rejected during the verification process due to conflicting information. So, check multiple times before submitting your medical claim to make sure that all the correct information is available.

How to Deal With a Health Insurance Claim Rejection?

If your health insurance claim gets rejected by your insurance provider, there is still a small chance that you can appeal again to get your claim re-reverified and approved. In case your claim has been rejected, you can take the following steps:

 

• Check the insurance claim form that you have submitted to your insurer for any discrepancies or mistakes in the details filled in or the documents submitted. In case you identify any mistakes in the submitted claim forms, you should immediately inform your insurance provider about the same.

• In case your claim has been rejected due to insufficient information provided, contact the customer service at your insurance provider and seek their help to identify and submit the missing information.

• If your claim has been rejected by the company due to a reason saying ‘procedure was not medically necessary’, you need to get an official opinion from a licensed medical professional that the procedure was medically important.

• If you feel that your claim has been rejected for no genuine reason, you can re-appeal by sending a letter to your insurer along with copies of all the important documents needed for making an insurance claim.

• If you feel like choosing a legal recourse for getting your insurance claim approved, you can contact the office of the Ombudsman or reach out to a lawyer.

How to Claim Your Health Insurance Correctly

There are certain points you should keep in mind and follow to ensure your insurance claims will not be rejected when the time comes:

 

• Provide Accurate Information: At the time of applying for health insurance, make sure that you provide the insurance company with all the relevant information about your pre-existing conditions and medical history. Do not skip out any details even if they are minor, as it could lead to claim rejection.

• Cashless Claim: At the time of your medical emergency, you should pick a hospital that provides a cashless facility. Under a cashless facility, you won’t have to pay any hospital bills, as all expenses will be covered directly by your insurance company. Most reputed insurance companies have a large number of hospitals under their network, so make sure the hospital you choose is part of your insurance company’s network.

• Keep Up Your Premium Payments: Make sure you make all your health insurance premium payments on time within your policy period. You will not be able to claim on a lapsed policy. Further, make sure to renew your policy on time before your current policy term expires.

• Keep All Records: As mentioned above, claims may be rejected due to insufficient documentation. So make sure you carefully save all the original copies of your hospital bills, as well as some photocopies.

To Conclude

Health insurance is an excellent way to keep yourself and your family protected against unexpected medical costs. However, if there are any mistakes during the claim process, you face the risk of your claim getting rejected. However, with all the information mentioned in the above points, you can make the insurance claim via the correct process to reduce the chances of claim rejection. If you do not have health insurance yet, you should take a look at the various health insurance policies available at Bajaj Markets and choose a plan that best fits your needs.