Many people believe that once they buy health insurance, their medical expenses will always be covered. However, when claims get rejected, it leads to frustration and financial stress. While some believe insurance companies reject claims intentionally, the reality is different. Most rejections happen due to errors, missed details, or a lack of awareness.
Understanding why health insurance claims are denied can help policyholders take the right steps to avoid rejection. Let’s explore the most common reasons for claim denials and how you can ensure your claim gets approved without trouble.
#Providing Incomplete or Incorrect Medical Information
When purchasing a health insurance policy, disclosing pre-existing conditions is crucial. Conditions like diabetes, heart disease, or hypertension should be mentioned at the time of buying the policy. Many people hide this information, assuming it will increase their premium or lead to rejection. However, this can backfire when they file a claim.
How to Avoid This Issue
- Always provide complete and accurate medical history.
- Do not hide any past or existing illnesses, even minor ones.
- If unsure about what needs to be disclosed, consult your insurer before purchasing the policy.
#Not Reading Policy Terms and Conditions Properly
Many policyholders skip reading the terms and conditions of their health insurance. Later, they are surprised to find out that certain treatments or procedures are not covered, or a waiting period applies to specific illnesses.
How to Avoid This Issue?
- Carefully read all policy documents before buying.
- Check the list of inclusions, exclusions, and waiting periods.
- If you have doubts, ask your insurance provider for clarification.
#Delay in Renewing Health Insurance
An insurance policy must be renewed before its expiry date. If a policy lapses, all benefits, including no-claim bonuses, are lost, and any pending claims can be rejected. Some people forget to pay the premium on time, leading to claim denials.
How to Avoid This Issue?
- Enable auto-debit for premium payments.
- Set a reminder for renewal dates.
- Keep track of due dates to ensure continuous coverage.
#Missing or Incorrect Documentation
Proper documentation is essential for claim approval. If hospital bills, prescriptions, discharge summaries, or diagnostic reports are missing or incomplete, the insurer may reject the claim.
How to Avoid This Issue
- Keep all medical records safely.
- Ensure hospital bills and reports are properly signed and stamped.
- Submit the required documents promptly.
#Claiming for Excluded Treatments
Not all medical treatments are covered under health insurance. Procedures like cosmetic surgery, dental treatments, and fertility treatments are often excluded. If you file a claim for such treatments, it will be denied.
How to Avoid This Issue
- Check your policy’s exclusion list before undergoing treatment.
- Consult with the insurance provider if you are unsure about coverage.
#Not Informing the Insurer Before Planned Hospitalization
For planned surgeries or treatments, insurers require prior intimation. If a policyholder undergoes treatment without informing the insurance provider, the cashless claim can be rejected.
How to Avoid This Issue
- Inform your insurer in advance for planned treatments.
- Obtain pre-authorization for cashless claims.
#Incorrect Claim Process
Filing a claim incorrectly or missing deadlines can result in rejection. Many people fail to follow the insurer’s guidelines, such as submitting claims within the given time frame or using the correct format.
How to Avoid This Issue
- Understand the claim filing process before hospitalization.
- Submit the claim within the stipulated time.
- Double-check forms and documents before submission.
#Hospitalization Not Meeting Policy Requirements
Some policies have specific requirements for hospitalization, such as a minimum number of hours (e.g., 24 hours). If a policyholder is admitted for a short duration or receives outpatient treatment that doesn’t qualify, the claim may be denied.
How to Avoid This Issue
- Ensure the treatment meets the minimum hospitalization criteria.
- If your policy covers daycare procedures, check the list of approved treatments.
#Policy Limits and Sub-Limits
Certain policies have limits on specific treatments, room rent, or total coverage per year. If medical expenses exceed these limits, the insurer may partially or fully reject the claim.
How to Avoid This Issue
- Be aware of policy limits, sub-limits, and co-payment clauses.
- Choose a policy that suits your medical needs and budget.
#What to Do If Your Claim Gets Rejected?
If your claim is denied despite following all rules, you have the right to challenge it. Here’s what you can do:
- Contact the insurer: Ask for clarification and the reason for rejection.
- Submit missing documents: If rejection is due to missing paperwork, provide the required documents.
- Appeal the decision: If you believe your claim was wrongly denied, file an appeal with the insurance company.
- Approach the Insurance Ombudsman: If your insurer does not resolve the issue, you can escalate the complaint to the Insurance Ombudsman for redressal.
By being cautious and well-informed, you can ensure your health insurance claim is processed smoothly. Taking these preventive steps will help you avoid unnecessary financial stress during medical emergencies.
