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How To Appeal Against Rejected Health Insurance Claims?

Updated On Apr 28, 2021

Insurance companies have an interesting justification to deny a health insurance claim. It is usually communicated at the same time as the claim application is being rejected. If not, a policyholder may make a request for it. Who can make amends (if possible) and reapply once you know the reason.

How To Appeal Against Rejected Health Insurance Claims?

How To Appeal Against Rejected Health Insurance Claims?

The claims team's first move after obtaining a claim application is to look up the applicant's policy details. Basic information such as the names of those covered, the fairness of the policy, and the inclusions are reviewed and validated. Here's a rundown of the major issues that cause claims to be rejected by the claims team:

  • A claim is filed for something that isn't protected by the policy.
  • When a policy expires, a claim is filed.
  • The claim application is lacking crucial information.
  • There is no supporting documentation (if any) given.
  • A claim is filed for anyone who is not covered by the agreement.
  1. Reapplying & Correcting

    If you've figured out why, fix it (if possible) and reapply. However, if the claim was rejected for reasons such as "claim raised for expired policy" or other similar reasons, the claim would not be admitted. Through contacting the insurance company's executive, make sure you understand the reason for the denial and how to fix it. On the phone or by email, the same can be achieved. In the event of such contact, it is preferable to provide a written trail mail.
  2. Approaching the Insurance Ombudsman

    The Insurance Ombudsman was established by the Indian government to assist policyholders in resolving grievances. To file a complaint against your insurer, write to the Ombudsman in your region. The complaint may be regarding a delay in settling a claim, a rate dispute, misrepresentation of terms and conditions, or other problems relating to the Insurance Act of 1938.
    The Ombudsman scheme is a non-judgmental and out-of-court system. In the event of a lawsuit, the Ombudsman serves as a mediator between the policyholder and the insurer, arriving at a reasonable recommendation based on the evidence available.
  3. Aim for the Future

    It is better to read and accept the terms and conditions of a policy before buying it or filing a claim for it, rather than suffering because of a wrongly purchased policy or a wrongly filed claim. Analyze your needs and buy a policy that meets them. In the policy text, the policy's inclusions and exclusions are stated clearly.

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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