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What To Do When a Health Insurance Claim Gets Rejected?

Updated On Apr 28, 2021

If you take measures such as making copies as a reference, of all the documents submitted along with the claim form to the TPA, go through the terms and conditions, the exclusions, deductibles, claim process, and most importantly the benefits of the policy, submit the claim request 30 days before the date of hospitalization, send all the medical records to the TPA.

In case of post-hospitalisation costs, the details and submission must be done within ninety days from the date of hospitalization. Double-check the insurance form for accuracy, gather sufficient information and proof such as doctor'sprescriptions, etc, and submit it to the TPA and your claim will not get rejected.

What To Do When a Health Insurance Claim Gets Rejected?

Firstly you must know why your claim was rejected. Despite a claim rejection the health insurance company may reconsider the case if it believes the claim is genuine. After figuring out the reason for rejection what you have to do is:

  • Check the names and your policy number. If there has been an error in reporting these the TPA will have to reopen the case and the insurer has to be intimated about the error.
  • A claim can be rejected even due to an error in the system caused by inadequate information provided by the person making the claim. The TPA representative will be able to help but you must record details of this conversation as well as the document if possible.
  • The documents sent must be thoroughly checked for mistakes made in the form of inadequate or incorrect documentation or even lack of attestation
  • Once the problem is figured out it can be corrected by providing necessary documents with correct details and attestation.
  • If the claim was rejected because the medical procedure was considered unnecessary get the opinion of licensed medical practitioners to support your claim.
  • After you have collected all related documents supporting your claim write a formal letter that states the reason for the claim being valid.
  • Attach appropriate supporting documents along with the medical opinion of a licensed medical practitioner
  • Remember that multiple appeals can be made for the claim validation
  • If in case the insurer does not respond to the claim in 30 days you have the option of approaching the Ombudsman. Over here you have to submit a written complaint within thirty days from when the health insurer has replied.
  • The Ombudsman is your last attempt to get your claim validated before you take legal aid which will be very expensive. So, you must ensure you have a valid claim with all necessary supporting documents.

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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