Why can your Health Insurance Claim get Rejected?

Why can your Health Insurance Claim get Rejected


A fantastic strategy to protect your cash in case you require medical care is to purchase health insurance coverage.  A policy is simple to purchase, but are claims always resolved when they are made? A claim could be rejected for a number of different reasons. If you can persuade the insurer that your claim is legitimate, the insurer may consider your claim after it has been rejected. To take corrective action, you must first understand why it was rejected.

Following are some major reasons for rejection of a Health Insurance claim

  • Repression and fabrication of facts
    • Non-Disclosures, partial disclosures, and incorrect disclosures of crucial information, such as
      • Age
      • Occupation type
      • Income
      • Current insurance plans
      • Serious illnesses, or pre-existing medical conditions
    • Any mismatch between the declaration and the reality at the time of filing claims might easily result in denial because coverage is provided based on the information provided by the proposer on the proposal form.
    • The best way to solve this issue is to complete the paperwork accurately and promptly.
  • Going over the allotted time
    • You have a set amount of time to submit a reimbursement request under health insurance coverage.
    • Regarding emergency admission, the time period is 24 hours following the patient’s admission.
    • It may vary depending on the type of policy you’ve chosen and the sort of treatment you’re receiving.
    • If you don’t submit your application by the deadline, your claim may be denied.
  • Disregarding the exceptions
    • The majority of health insurance plans do not offer coverage for a number of conditions. These are clearly listed as “not covered” in the policies.
    • These are sometimes referred to as exclusions and are essentially diseases for which you cannot submit a claim.
    • There will be a waiting time in place for any such condition, though, if certain plans or policies cover it.
    • If you submit a cashless claim for a disease or medical condition that is prohibited, it will undoubtedly be denied.
  • Surpassing the Sum Insured
    • Whether you choose a family floater or an individual health cover, there is an insured sum whether you choose a health insurance policy or a personal accident policy.
    • The sum insured is the annual amount that you or your family have access to, depending on the plan you’ve chosen.
    • If you use up all your allowance for a given year, your subsequent cashless claims will be denied.
    • However, the insurance might reimburse you in the future if some of your sum assured is still in tact.
  • Pre-existing Illness
    • Policy holders may get insurance with the intention of using it for future treatment, but they forget that pre-existing conditions are not covered and try to hide the medical information, which can lead to a claim being denied.
    • Pre-existing conditions, including high blood pressure, are typically not covered by insurance providers or covered only after a certain waiting period, thus any related medical costs will not be reimbursed.
    • Usually, this is done to stop people from purchasing the insurance right before being admitted to the hospital for an existing medical problem.
  • Policy lapse
    • There have also been instances where customers waited a week or a month to renew their insurance, fell ill, and rejected their claims.
    • The reason for this is that the policy expires on its last day. Therefore, even if a person is admitted to the hospital a day later, their insurance will not be functional.
    • It’s crucial to renew the coverage each year before the cutoff date because of this.
  • Claims procedure
    • You must carefully follow the claim procedure because your health insurance policy is a contract between you and your insurance provider.
    • Application forms that have been erroneously or incompletely filled out, a lack of supporting documentation, etc.
    • It is advisable to speak with the insurance provider to learn how to file a claim for health insurance. The likelihood of a claim being rejected will be decreased.
  • Waiting time
    • A waiting period for a health insurance plan refers to the amount of time you must wait before using the insurance.
    • For instance, after a two-year waiting period, some insurers cover pre-existing conditions or maternity benefits.
    • The time frame is determined by the insurance company’s terms and conditions. If you raise a condition for which there is a specific waiting period, your claim will be denied.

My Health Insurance Claim got Rejected

Steps to take in case the claim gets rejected:

  • Finding out why your claim was denied should be your first step because only then can you attempt to make amends.
  • Contact your insurance provider and the third-party representative or TPA to let them know that you want to resubmit the denied claim if you believe you have a valid basis to do so.
  • You may need to update some information based on the reason your claim was denied:
    • If the missing or wrong documents were the cause, make the situation right by giving the required documents along with the proper information and attestation.
    • Check your claim form carefully for mistakes, such as your name or the policy number, and have them fixed.
    • You can submit your treating doctor’s letter or prescription recommending hospitalization as well as any pre-hospitalization diagnostic reports to your insurer or TPA to persuade them that it was necessary to receive the treatment and stay in a hospital in the event that your claim was denied because your insurer felt that the hospitalization or medical procedure was deemed unnecessary.
  • Once you have gathered all the evidence to support your claim, including all the supporting papers, facts, and any additional information, you must:
    • In a formal letter to your insurer and TPA, provide your justification for the claim’s validity, the right policy number, and the specifics of the claim.
    • Send your insurer a copy of this letter along with all necessary paperwork and a letter attesting to the claim’s validity with the medical judgment of a qualified physician.
    • Keep in mind that you can appeal your claim many times.

Conclusion: You should thoroughly understand your health insurance coverage, ideally from the moment of purchase, to prevent claim rejection. Additionally, it is important to keep track of all your paperwork, including pre- and post-hospitalization costs, hospitalization records, diagnostic test results, discharge summaries, and investigation findings. These records may be vital if your insurance company requests clarifications.

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