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Health Insurance Claim - Ways to Avoid Getting It Rejected

Updated On Dec 04, 2020

With regard to health insurance, people believe different things and hold on to several theories about the rejection of health insurance claims. However, very few strive to find the reasons for it and ways to avoid claim rejection in the future, and rather most remain focused on the seemingly lucrative elements of the insurance plans.  Additionally, people tend to focus more on short-term benefits such as the amount of premium or tax exemptions and lesser on the exclusions and limitations of the policy. This is a significant cause of claim rejection of their health insurance plan. Here are some factors to consider for avoiding the rejection of your health insurance claims:

      Carefully Read the Terms and Conditions of the Plan

Customers often remain unaware of the rules, inclusions, exclusions and other significant elements of the policy purchased. Most customers do not take the time and effort required to carefully read the documents of their medical insurance policy, which in turn leads to misgivings and lack of understanding of the ‘fine print’ and essential highlights of the plan. It is imperative to read the terms and conditions of the plan, especially within the free look-in-period, which enables policyholders to accordingly plan any medical exigencies and treatments covered under the policy.   

Share Correct and Accurate Information

Often the claims are rejected due to misrepresentation of health and or the basic details of the policyholder - this information may include pre-existing medical condition, age, a major illness, income, and more. This occurs when inaccurate information is provided by the customer or entered incorrectly by the agent or someone else. It is highly recommended that customers should take the time to complete and sign all the forms or at least review before submitting and after the agent has input the details. This maintains transparency as well as accuracy benefiting both the customer and the insurance company.

Availing of Relevant Medical Procedures Stated in the Policy

Policyholders must verify the details of the medical plan repeatedly before availing any medical treatment/procedures. Undergoing an unlisted treatment or availing treatment at a hospital not part of the network hospitals mentioned could be reasons for claim rejection. Therefore, verification related to all the policy details is essential and critical. It is recommended that policyholders check with the agent from the insurance company in case of doubts since even the slightest deviation and ignorance on the part of the insured could result in excess costs owing to claim rejection.  

Take a Plan for the Offerings and Benefits – Do not Base on Premium Amount

Insurance companies and agents offer several policies at a low premium to allure customers. While an economical medical insurance scheme makes sense, it is imperative that those seeking health policies are not distracted by attractive price offers. It is necessary to opt for policies that offer good benefits and coverage, and best suit the requirements of the insured. It is widely observed that many people buy affordable plans but regret these later at the time of treatment when the offerings do not match their requirements. Discovering that basic plans do not possess many or every health-care need required during treatment, can add to stress and financial crunch.

      Always Opt for Pre-authorization Wherever Possible

Many insurance firms expect a request from the treatment provider of the policyholder, accompanied by an explanation with regard to the need for a particular treatment. It is common to seek pre-authorization before availing a service to confirm medical eligibility. It becomes the responsibility of the insured to check whether the medical centre/hospital at which treatment may be done, owns the approval for specific treatment or a pre-authorization is required. In addition, it is necessary to verify if the health insurance plan needs referrals for some services such as meeting a specialist, and more.

We reiterate the importance of thoroughly reading the details of health insurance plans before choosing one. Ensure that the network hospitals are in the vicinity or at least not too far from home. Thoroughly check the coverage of specific procedures – for example, emergency services may be covered in a plan but not radiology. This is a helpful list that would save you from any unpleasant surprises and rejection at the time of policy claims.

Also Read 

Everything You Should Know About Fraudulent Health Insurance Claims

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