Top 6 Reasons Health Insurance Claims Get Rejected

An unexpected medical emergency that calls for hospitalization or prolonged hospital stay often comes with its share of anxiety. In such a situation, health insurance serves as a safety net, offering you the peace of mind of knowing your medical expenses are covered.

However, imagine the distress one can face if their insurance claim gets rejected and they have to pay from their pockets. This can be a nightmarish experience for anyone, leading to unnecessary stress and financial stress on the insurer.

Table of Content

• Top 6 Reasons for Health Insurance Claim Rejections
• Tips to Avoid Health Insurance Claim Rejection
• How to Deal With Health Insurance Claim Rejection
• Conclusion

To safeguard against these potential pitfalls, it is crucial to understand the common reasons behind health insurance claim rejection.

Top 6 Reasons for Health Insurance Claim Rejections

Incorrect or Wrong Information

The most common reason for claim rejection is providing wrong or incorrect information on the claim form. While applying for an insurance claim, you need to fill out a claim form that asks for basic information like age, name, phone number, etc. Any accuracy in this form can lead to the rejection of the claim due to discrepancy.

Requesting Claim in Waiting Period

Most health insurance companies have a waiting period for pre-existing conditions, maternity, specific alignments, etc. If you place your claim during this waiting period, then it's more than likely that your claim will get rejected.

Non-Disclosure of Existing Conditions

Another common reason for claim rejections is the non-disclosure of existing conditions. When you buy health insurance, you need to disclose all your pre-existing conditions. If you fail to disclose the conditions and the insurer discovers them later, they have the right to reject your claim.

Delay in Filing the Claim

Every insurance company has a specified time frame within which you have to submit the claim. If you forget to claim within the time frame, the insurer can deny your claim request.

Exhaustion of Sum Insured in Previous Claims

Each health insurance policy has a defined sum insured limit, typically applicable within a policy year. Once this limit is reached due to previous claims, you may not be eligible to file further claims within that policy year. Similarly, if the cost of a single medical event exceeds your sum insured, the insurance company will only reimburse up to the policy limit. Any expenses exceeding the sum insured will be your responsibility to cover out-of-pocket.

Lapsed Health Insurance

A health insurance policy lapses if the premium payment is not made within the grace period. A lapsed policy becomes inactive, and the insurance company is no longer obligated to provide medical coverage to you. That’s why, any claims submitted using a lapsed policy will be denied by the insurer.

Tips to Avoid Health Insurance Claim Rejection

Here are some tips to avoid getting your health insurance claim rejected:

1. File Claim on Time: Make sure to inform your insurer about your hospitalisation and submit the claim within the time frame. For emergency hospitalizations, inform the insurer within 24-48 hours of admission. For planned hospitalizations, provide at least 2-3 days' advance notice to the insurer.
    
2. Provide Accurate and Detailed Medical Information: Provide all your medical information accurately while buying health insurance. Also, make sure to declare all your pre-existing conditions.
    
3. Renew the Policy on Time: To prevent your policy from lapsing, renew it on time. Insurers typically send renewal reminders to policyholders at least 15 days before the policy's expiration date. Upon receiving the reminder, promptly renew your policy to ensure uninterrupted coverage.
    
4. Cashless Treatments at Empanelled Hospitals: In case of cashless treatment, ensure that you get admitted at a partner hospital of your insurer.

Suggested Read: How to Make a Health Insurance Claim?

How to Deal With Health Insurance Claim Rejection

Here are some ways to deal with insurance claim rejection:

1. Discuss with your insurer to understand the reason for rejection.
    
2. If the reason for rejection was incomplete documentation or missing information, ensure that you provide accurate information or documentation promptly.
    
3. In case you believe the insurance rejection is incorrect, you can appeal to the insurance company. To do this, you need to submit a written request explaining your case along with supporting documentation.
    
4. If your appeal is denied, you can also escalate the matter to the Insurance Ombudsman. An insurance Ombudsman is an authority that deals with disputes between the insurer and the policyholder.
    
5. If these steps fail to resolve the issue, consult with an attorney specializing in insurance law. They can advise you on your legal rights and explore potential legal options to address your claim denial.

Conclusion

As we conclude, it is clear that insurance claim rejection can be a stressful time for many. But, by understanding common claim rejection reasons and following the tips, you can significantly reduce the risk of your claims being denied.

If you are looking for the best insurance policy, consider exploring Muthoot Finance. As a trusted leader in financial services, we offer a comprehensive range of health insurance solutions tailored to meet diverse needs. Enquire online by filling the query form or visiting your nearest Muthoot Finance branch.