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What is Claim Rejection and Claim Repudiation in Health Insurance?

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The process of claiming health insurance can be challenging for policyholders, as they might face claim repudiation and claim rejection. Medical claim repudiation happens when the insurance company denies reimbursing the claim after it has been processed. Whereas the claim rejection happens due to errors and differences in the claim, it is important to understand the reasons for claim rejections and repudiations to avoid any such cases. Let us explore more about the reasons for claim repudiation and rejection and some tips for customers to follow to resubmit their claims.

Claim Repudiated vs. Claim Rejected 

In the process of claiming health insurance, it gets rejected and repudiated sometimes as in both cases the policyholder's claim is denied. Claim repudiation occurs when the claim is processed, but the insurance company finds it unpayable for various reasons. Whereas, claim rejection happens when the claim gets rejected before getting processed or submitted due to errors or differences. Both cases are important for policyholders to understand the process and steps to be taken to resubmit the claim after a denial.

What is Health Insurance Claim Repudiation? 

Health insurance claim repudiation means when the claim has been processed by the insurance company but is unpayable for various reasons the claim not meeting the policy terms and conditions of the health insurance coverage. When an insurance company repudiates a claim, it notifies the policyholder with the reasoning and decision in writing. Policyholders may sometimes have to appeal the claim repudiation by providing the necessary information, documentation, and evidence to support the claim.

To avoid claim repudiation, it is considered important for policyholders to understand the terms and conditions of their health insurance coverage and take professional advice from advisors and legal professionals.

Why are health insurance claims repudiated? 

Various reasons are considered responsible for health insurance claim repudiation. Some of these common reasons are:

1. There is a list of exclusions, like specific treatments, conditions, and services, that are not covered under the policy. If the claim has any exclusions, then it might get repudiated.

2. Any pre-existing health conditions may not be covered by your health insurance coverage.

3. Incomplete documentation like medical records, bills, diagnostic tests, prescriptions, etc. often leads to claim repudiation.

4. If the policyholder has violated any policy terms and conditions, then the claim can be repudiated.

5. If the policyholder has not paid premiums or has any policy lapses, the claim submitted may not be covered and repudiated.

What is Health Insurance Claim Rejection? 

Health insurance claim rejection happens before the policyholder claims anything. This rejection can happen due to any reason, like wrong information related to a pre-existing disease, age, nature of the occupation, etc. It is different from claim repudiation, as in claim rejection, it does not meet specific criteria of the policy.

When a claim is rejected, the policyholder is informed of the detailed reason for it. Policyholders should make sure that the information provided is correct, that the medical procedures and diagnoses are as per policy, and that claims fall under policy limitations, exclusions, etc., to avoid different claim rejection cases. However, the claim can be eligible for resubmissions with different corrections and added necessary information.

Why are health insurance claims rejected? 

Various reasons are considered responsible for the rejection of health insurance claim rejection. Some of these common reasons are:

1. The health insurance policies have some exclusions regarding services, treatments, conditions, etc. that are not covered under the policy. And if the claim has any exclusions, then it might get rejected.

2. Incomplete documentation for the claim or any violations of the policy terms and conditions can lead to policy rejection.

3. Any errors and differences in the billing process, like duplicate claims, wrong billing amounts, wrong codes, etc., can lead to claim rejection.

4. Unnecessary medical treatments that are not as per policy guidelines might lead to claim rejection.

5. Insurance providers conduct investigations after getting the claim, and if the company suspects any fraud in the claim, then it might get rejected.

6. If the individual has not paid the premiums of the policy, then the claim might not be covered and get rejected.

What to do if your health insurance claim has been repudiated or rejected?

If your health insurance claim has been repudiated or rejected, then you can follow some steps to resubmit it by making simple changes like,

1. You should first carefully review the claim rejection or claim repudiation letter sent by the insurance company to understand the reason.

2. It is recommended that you contact the customer support section of the insurance company to seek professional guidance and clarification.

3. If the policyholder believes that his or her claim was justified, then he or she can get support from the appeal section and resubmit. Collect any helpful documents or evidence that can help you resubmit the claim, like medical records, treatment plans, tests, etc.

4. Make sure you submit the appeal as per the deadline and include all the important documents needed to get your claim approved.

Conclusion

Some steps can be considered by policyholders to avoid cases of medical claim repudiation and claim rejection. The reasons behind policy claim rejection and repudiation can be identified and rectified beforehand. Appealing for a claim or appealing for a rejected claim can both be resolved with proper knowledge of health insurance and appropriate guidance.

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

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