Common Reasons Why Health Insurance Claims Get Rejected

Considering the rising healthcare costs, a well-designed Health Insurance plan can become an indispensable ally and ease the burden of medical expenses while ensuring that quality healthcare remains within your grasp.But purchasing such a policy is the first step in safeguarding your health. You must also understand and follow policy guidelines to prevent having your claim denied by your insurer, which might leave you disheartened and frustrated. To avoid such situations, learn about the list of reasons why Health Insurance claims might get denied. This article can also help you with some tips if you wish to re-submit your claim. Also read: What is General Insurance?

A Health Insurance policy provides financial protection from expenses arising from unforeseen illnesses, accidents, or other healthcare needs. You can avail financial coverage for medical services outlined in your policy by paying regular premiums.You can purchase several types of Health Insurance plans, from Individual Health Insurance to Family Health Insurance, Senior Citizen Health Insurance to Top Up Health Insurance , and more. Carefully examine each type of policy to determine which one matches your specific requirements.

Health Insurance claims can be rejected for several reasons, from incorrect information in your submitted documents to undergoing experimental treatment. Here are a few common reasons why your claims can be rejected.

Delay in informing the insurer:

Your insurer should be immediately notified as and when a medical situation arises. Ideally, your insurer should be informed before hospitalisation in case of planned situations or within 24 hours of hospitalisation in emergencies. This information can be communicated by calling your insurer or emailing the customer service helpdesk. Failure to do so within the specified period may result in your claim being rejected. Most hospitals offer an insurance helpdesk service, which can assist you in promptly notifying your insurer about the medical issue.

Claims made for costs excluded by your Health Insurance policy:

Another reason your claim might be rejected is if you make claims for costs that are not under your policy's purview. As a rule of thumb, claims related to dental care, cosmetic surgeries, or pregnancy-related issues are not usually covered under most Health Insurance policies. Read your policy's terms and conditions carefully to understand the types of medical problems covered by your insurance and the limitations that prevent you from obtaining financial reimbursement.For instance, Health Insurance policies may usually not cover the medical costs of those who incurred illnesses 48 months prior to purchasing the said policies. These 'pre-existing' illnesses can span from high blood pressure and diabetes to terminal illnesses such as cancer. If you have a pre-existing illness, purchase a Health Insurance plan that meets your specific requirements. This will prevent you from dealing with complications in case your claim is rejected.

Claims made within the waiting period:

The waiting period is a pre-determined time span which you must wait out before you can avail of certain benefits offered by your Health Insurance policy. Any claims made during the waiting time may be denied by your insurer, with a few exceptions, such as emergency hospitalisation.The waiting period may differ based on the insurer, the type of Health Insurance policy you have, specific health or medical conditions, and so on. For instance, the waiting period for a pre-existing illness is usually between two and four years, only after which you can make claims related to medical costs covered by your policy. However, some policies allow you to reduce this waiting period by paying an extra premium.

Exceeding the sum insured amount:

The sum insured is the maximum amount an insurer will pay for your medical expenses in a year. If this upper limit is exhausted within one year, any further claims may be rejected, and you will be responsible for the excess costs.Let us understand this with a simple example. Assume that your sum insured is ₹ 10 lakhs per year. Now, consider that you have been hospitalised thrice a year, and your medical costs come up to ₹ 5 lakhs, ₹ 3 lakhs, and ₹ 4 lakhs, respectively. In such a case, your insurer will pay ₹10 lakhs related to your medical expenses, but you would have to pay the remaining ₹ 2 lakhs.If you feel that your sum insured is insufficient to cover medical costs that may arise in the future, there are a few ways to rectify the situation. Most insurers allow you to increase your sum insured during renewal by agreeing to pay a higher premium. Another way to do the same is by buying a top-up plan, which adds another layer of financial cover in case you have exceeded your Sum Insured figure.

Providing inaccurate information:

Incorrect or erroneous information on your personal data, or of those covered under your Health Insurance policy, may result in your claim being rejected. This includes information related to age, income, occupation, current insurance policies, pre-existing illnesses, etc. Similarly, if there are any irregularities in paperwork relating to hospital bills, doctor prescriptions, medicine invoices, and so on, your claim may be rejected by your insurer.To avoid any unnecessary hassles, try to be as transparent as possible while filling out your personal documents and initial paperwork when buying a Health Insurance policy. As an added tip, make sure your personal identification documents are also accurate and valid.

Niche cases in which your Health Insurance claim might be rejected:

Apart from the common cases mentioned above, there can be niche situations where your Health Insurance claims may be rejected. Such a situation could arise if you have filled incorrect information about your medical history. Although you do not have to mention every trip to the doctor while purchasing Health Insurance, it is important to disclose information regarding recent treatments or the latest surgical procedures you have undergone.Furthermore, remember that claims associated with experimental or unproven treatments may be rejected unless specific provisions are mentioned in your policy. Another reason for claim rejection is if your insurer disagrees with the diagnosis or treatment plan proposed by you (the policyholder). Also read: What is the waiting period in Health Insurance policies?

• When buying a Health Insurance policy , it is crucial you disclose all the necessary information regarding your health conditions, previous ailments, family medical records, personal habits, and so on. This can help you avoid unnecessary complications when filing a claim.
• Inform your health insurance provider about the hospitalisation or medical treatment as soon as possible.
• Fill out the claim form provided by your insurer and submit it within the prescribed time limit.
• Re-check the insurance claim form before submitting it and ensure all the information has been correctly entered.
• Keep copies of the documents you submit to your insurance company. This way, you would not have to backtrack and produce such copies again if your claim gets rejected.
• If your insurance policy offers a cashless facility, you can get treatment at network hospitals and follow up with your TPA or the hospital.
• Try to submit your claim as early as possible and make sure that all your medical records are sent to the Third-Party Administrator (TPA) to ensure transparency with your medical treatments.
• If there are delays in processing the claim or if you need any further information, follow up with the insurance company's customer service regularly to check the status of your claim.

• Understand why your claim is rejected and discuss the matter with your insurer. Seek clarification on the specific reasons for claim rejection.
• If the rejection was due to incomplete documentation or missing information, ensure that you provide the necessary documents promptly.
• If you believe the rejection is unfair, you have the option to file an appeal with the insurance company. This step involves submitting a written request explaining your case and providing any relevant supporting documents.
• You can escalate the matter to the Insurance Ombudsman if the insurer denies your appeal. The Ombudsman is an independent authority that mediates disputes between policyholders and insurance companies.
• If none of the steps work, consult a lawyer specialising in insurance law to understand your rights and explore further legal options.

• Health Insurance plans provide financial protection against medical expenses, but understanding and following policy guidelines is crucial to avoid claim denials.
• Reasons for claim denials include delayed notification to the insurer, claims for non-covered costs, claims made within the waiting period, exceeding the sum insured amount, providing inaccurate information, and niche cases such as undisclosed medical history or experimental treatments.
• Tips to prevent claim denials: promptly inform the insurer about medical situations, understand the coverage limitations, disclose pre-existing illnesses, be aware of waiting periods, monitor and manage the sum insured, provide accurate information, keep copies of submitted documents, and submit claims early with complete medical records to ensure transparency with the insurer and Third-Party Administrator (TPA).