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When Can Health Insurance Claims Be Rejected?

Published On Apr 13, 2019 5:30 AM By Sakshi Aggarwal

Health insurance is the need of the hour. We all purchase one to get covered by the medical contingencies. But the rejection of health insurance claim settlements can drop you into sheer despair. Sometimes the health insurance companies are at fault, while sometimes the policyholders take the blame.

So, before you bump onto blaming the health insurance company, it is better to ask yourself a few questions-

  • Was there any information on a pre-existing disease that you did not disclose because it seemed unimportant to you? For instance, symptoms of hypertension, before the policy was purchased.

           Was the claim made for illness not covered in your health insurance policy? For instance, health insurance claims for cosmetic surgeries or dental treatments.  

  • Was the claim made on hospitalization, not for treatment, but only for a diagnostic purpose?
  • Was it a claim for any self-infliction condition? For instance suicide attempt, or even lung cancer due to smoking or drinking? 
  • Was it a claim for the condition listed in permanent exclusion? For instance, pregnancy, genetic disease or injury during a nuclear war, and so on.
  • Were you unable to present the required documents? This could be a document which you might have considered unimportant when filing the claim.
  • Did you intimate the insurance company after the specified date or much later than the hospitalization?  
  • Did you make the claim in the waiting period?
  • DID you make the claim after you used the SI or for more value than the SI? 
  • Was the claim more than the sub-limits applied?  
  • If your answer to any of these questions is affirmative, then sadly, the rejection is valid. You may not be able to do anything about it, leave aside blaming the insurance company, as these small things are specified in the policy clause provided to you. And thus it is said that one should carefully read the policy documents.

What should be done now?

Losing trust in health insurance is not the way out. The policyholder is supposed to know all the terms and conditions of the health insurance policy and also why claims were rejected, in order to avoid the nuisance. Given below are some steps that ensure a smooth claim settlement process for the insured. 

1. Full disclosure: Even the minutest detail about existing ailment must be disclosed to your insurer. It may increase your premium, but you will be ensured of your health insurance claims to be honoured. 

2. Follow the claim procedure: Be fully conversant with the steps to be followed in case you need to raise a valid claim in the future. 

3. Renew your plan every year: Not immediately after buying a policy, but someday you would require to make a claim. For instance, when a disaster strikes, you might need a valid plan to bear the related expenses. You should, therefore, renew your plan every year to ensure continued coverage.   

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Take Away

In short, the possible reasons for claim settlement rejection maybe 

1. Incomplete or wrong disclosure information 

2. Incorrect health insurance claim procedure

3. Health insurance claims for permanent exclusions

4. Health insurance claims for temporary exclusions

5. Claims on lapsed policies 

So, now you know why your claim can be rejected and how to avoid it. Make the best use of your health insurance policy by getting a thorough understanding of the claim settlement process and requirements stated in your policy. Make sure you don’t miss out on any document. Also, the policyholder can lodge a written complaint about his/her claim rejection within a specified period of time that is generally 30 days after the company’s response. If in case you have understood the reason for claim rejection and are ready with supporting documents to prove the validity of your claim in order to file an appeal. You can appeal any number of times until your claim gets approved. 

So, a few precautionary measures mentioned above can save you from all the trouble and stress of rejection of health insurance claims. All you need to do is, stay informed and keep informing!  

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