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Health insurance claim rejected? These could be the reasons

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In today’s uncertain times, health emergencies come without any warning. If you have a health insurance policy, you can avail of quality and timely treatment without worrying about the crushing medical bills.However, health insurance companies set some pre-conditions for a valid claim. It means that there can be certain medical expenses your insurer may not cover and reject any claim made against such exclusions. Apart from these, there are other factors too, that might lead to health insurance claim rejection. Read on to know about health insurance and the situations when the chances of your claim being rejected are high.

Health insurance policy

Health insurance is a type of insurance that financially protects you during medical emergencies. It covers medical expenses related toan accident or illness that leads to hospitalisation. A health plan covers doctor consultation fees, surgery costs, hospitalisation expenses, cost of medicines, ambulance charges, daycare procedures, and mental healthcare, thereby, protecting the insured from financial strain.

Insurance companies offer different types of health plans for individuals, families, parents, senior citizens, and women. There are plans to cover critical illnesses and COVID-19 as well.

What is a health insurance claim?

If a policyholder meets with an accident or is admittedto the hospital due to a medical emergency, they can submit a claim request to the insurance company.The insurer will review the claim and accept it or reject it based on the policy terms and conditions. This is what a health insurance claim is.

When a claim is accepted, the insurance company takes care of your hospital bills and saves you from financial hassles.

8 scenarios in which your health insurance claim may get rejected

After going through the harrowing medical ordeal, the last thing you want is your health insurance claim being rejected. However, this is a possibility, especially if you do not fill the right information, submit the wrong documents, etc. Below we address eight scenarios where you will face claim rejection.

1.      Wrong information in the claim form or policy document-In case you provide incorrect or incomplete information in the form while buying a policy, your insurer may reject your claim. Therefore, do not hide any pre-existing medical conditions from your insurer. If you do so, your insurer will not cover you for the illness whenever you file a claim. Also, when you are filing a claim form, enter all the information correctly, such as the patient’s name, doctor’s name, health condition for which you were admitted to the hospital, and more.

2.      Submitting the wrong documents-Sometimes, it is just a matter of filing the wrong documents when making a claim. Thus, always double-check the claim documents before submission. These include your medical reports, hospital bills, discharge summary, and prescriptions. The documents should have the correct information for a hassle-free claim settlement.

3.      Not knowing about the exclusions-Every insurance policy has a set of inclusions and exclusions. For instance, your insurer may not cover claims related to self-inflicted injuries, adventure sports injuries, cosmetic procedures, alternative treatments, and wars. If you file a claim for any of the excluded perils, your insurer will reject it. Hence, it is important to read the policy documents, especially the inclusions and exclusions, before purchase.

4.      Not getting prior authorisation- You may require prior authorisation to avail of certain benefits of a health plan, such as cashless hospitalisation and non-emergency benefits. If you do not take prior authorisation from your insurer, your claim may be denied.

5.      Late filing of a claim-Insurers offer a maximum of 60 to 90 days from the date of discharge from the hospital for filing a claim. If you wait for too long, your claim may get rejected. To avoid this, file a claim soon after you are released from the hospital.

6.      Waiting period-There is a waiting period for pre-existing conditions and you cannot submit claimsrelated to such conditionsbefore the waiting period is over. Certain health conditions have a waiting period of around 3 to 4 years. Therefore, if you file a claim for a condition that is still under the waiting period, your claim will be denied.

7.      Policy has expired-If you do not renew your policy on time and file a claim on the expired policy, your insurer will reject the claim. While insurance companies offer a grace period for policy renewal, your insurer may not accept your claim during this period. Therefore, it is important to renew your policy on time to avoid such situations.

Insured sum is used up- If you have made some claims on your policy within the same policy year and the sum insured is used up, your insurer will deny new claims.To avoid such unwanted surprises after filing a claim, make sure you read the policy terms and conditions carefully while making a purchase.

Conclusion:

If you file a health insurance claim and it gets rejected, you can talk to your insurer and try to find a solution. For instance, if your insurer has rejected your claim because of missing information or documents, you can share the pending details and submit the documents again.Also, make sure you renew your health insurance policy on time and keep it active so that you can file a claim during a medical emergency.

Disclaimer: The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales.

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