Things To Do After Your Health Insurance Claim Is Rejected
Updated On Oct 18, 2022
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We often buy health insurance to secure ourselves and our dear ones financially in case of any medical emergency. But, somehow lying to the insurance provider may lead to the non-settlement of the health claim.
We all are familiar with the most common reasons for claim rejections, but how many of us know the next step to follow in this situation? Continue reading to check the steps to be taken in case of claim rejection.
What To Do When Your Health Insurance Claim Is Rejected?
Health insurance providers are there to financially support their policyholders. Needless to say, there is a lot of trusts involved in the contract between the insurer and the insured. Whenever, this trust breaks due to failure in providing accurate and complete information from the insured individual’s side, the insurer is left with no option, but to reject the health insurance claim.
Thus, it is advisable to provide relevant and correct information to an insurance company while purchasing a health plan. However, if your claim is rejected than you can follow the below-mentioned steps:
- Firstly, look for the errors in your submitted claim form. There might be chances that the claim rejection you had to face is because of inaccurate and incomplete information submitted by you, whether knowingly or unknowingly.
- If not sure how to do it, then you can contact third-party representatives or TPA to rectify the errors in the claim form and provide the correct information.
You should always fill up your claim form correctly without any errors as a minor mistake or ignorance could become a burden at the time of an unexpected medical emergency. Besides mental peace, you will not be able to have financial assistance during your tough time.
How Can You Prevent Claim Rejections For Your Health Insurance?
Following are the points that you should remember while purchasing health insurance plan in order to avoid claim rejections:
- Remember to make multiple copies (for future reference) of each document submitted along with the claim form for the health insurance plan to the TPA.
- The policyholder must deliver all medical records to the TPA. If there is a chance that you will have post-hospitalization costs, you must provide details and submit your claim within 90 days of the hospitalisation date.
- Make sure you thoroughly read all of the terms and conditions before signing the health insurance policy document. Pay particular attention to the deductibles, claim procedures, exclusions, and benefits covered under the policy.
- Ensure that the claim request has to be submitted by you to the health insurance company 30 days prior to the hospitalisation date.
- Make sure to double-check your claim form before submitting it in order to maintain accuracy. It is recommended to keep multiple forms handy in case there comes a need to re-fill the form before submission.
- Make sure you are submitting all the medical records to a third-party administrator(TPA). If you incur any post-hospitalisation expenses, then the information and submission must happen within 90 days from the hospitalisation date.
- Collect all the relevant documents and proofs such as medical bills, doctors' prescriptions, etc to submit in time to the third-party administrator.
Besides this, were you aware of the fact that in case of claim rejection, you can urge your insurance provider to reconsider it? Yes, you can apply again and convince the health insurer that your claim is 100% genuine. However, before that, it would be significant for you to know the exact reason your claim was rejected so that you can take the next step accordingly.
Steps To Follow After Claim Rejection
Please follow the below-mentioned steps according to the mistake you have made:
- Thoroughly check your medical insurance claim form, which you have submitted to your health insurance company. Check your name and the policy number. In case, there are errors in the same, inform your TPA to reopen the case. Note that your insurer should be aware of this error too.
- Inform your TPA representative if you discover that you haven't given your insurer enough information so that a solution can be offered. Don’t forget to record details regarding the conversation as well as documents, if possible.
- Check the documents you have sent with the claim form. Analyze if any mistakes have been made, whether in the form of incorrect or insufficient documentation or lack of attestation. As soon as your figure out the real problem, get it corrected by providing the desired documents with correct details as well as attestation.
- Get opinions from licenced medical professionals to support your claim if your claim was rejected because of an unnecessary medical procedure.
Prepare all the necessary documents to back up your claim. What you must do is as follows:
A formal letter that offers your justification for the claim being true or legitimate should be written and sent along with the statement.
To support your claim, enclose the proper documents and the licenced doctor's medical judgment.
What If You Do Not Get Any Response From the Insurance Company?
In case, you don’t get a response from your health insurer within 30 days, go ahead and approach your Ombudsman.
Beyond approaching the office of the ombudsman, you can opt for legal help. However, remember that availing of legal aid might cost a lot.
Therefore, it would be better if you have a valid claim as well as sufficient supporting documents in the first place to avoid rejection and the struggles associated with it.
Steer Clear of Health Insurance Claim Rejection Proactively
At the time of buying a health insurance plan, insist on going for a healthcare check-up. If there is no need of undergoing a medical test as per the policy requirement (generally individuals who are aged below 46 years are not required to go through any pre-policy health check-up in various cases), make sure that there is a revelation of your current health status in your policy document and don’t forget to keep an acknowledgement of the same.
It is advised to choose a cashless health insurance plan since in such cases, the insurance company must grant the hospital's request in advance. It is a superior option because the insurance company pays the hospital directly, there is little paperwork involved, and the claim settlement procedure is quick and easy.
Moreover, according to the Insurance Regulatory and Development Authority Of India( IRDAI), none of the insurance providers can deny your claim if you have been regularly paying your premium for 8 years. However, keep in mind that some transparency and clearly presenting the information from your end might go a long way toward reducing the likelihood that your health claim will be rejected.
At Last
It is advisable to check your claim form thoroughly before submitting it and provide all the relevant information relating to your treatment to your insurance provider. You can reach us at 1800-1205-698 if you wish to speak with one of our specialists about the denial of your insurance claim.
Also Read:
Easy Ways to Pay premium for National Health Insurance Policy Online
