5 Reasons your health insurance claims may get rejected

Let’s look at the 5 most common reasons for a policy rejection and ensure that we are adequately safeguarded against a rejection.

August 28, 2020 7:25 IST | India Infoline News Service
Health insurance
A health insurance secures you and your family in an event of sudden illness or an accident. And this has never seemed as urgent and essential as it has been in the midst of this ongoing pandemic. In today’s times, a policy is easily accessible given that everything is pretty much online. Though one receives guaranteed health insurance claim, chances are that the same might get rejected due to some reason you were not aware of. In order to prevent this from happening, let’s look at the 5 most common reasons for a policy rejection and ensure that we are adequately safeguarded against a rejection.
  1. Suppression or non-disclosure of illnesses: Hiding pre-existing diseases is one of the major mistakes made by those looking for the best health insurance policy.  Assuming that the insurers won’t provide insurance, many people avoid disclosing their actual health conditions. Coverage is provided on the basis of the information given by the proposer on the proposal form, so any discrepancy between the declaration and the reality during the time of filing claims can easily lead to rejection. The only solution to this problem is to be prompt and specific while filling forms.
  2. Exclusions:  This specifically applies in the case of COVID-19. If the insurance policy categorically mentions that it does not cover pandemics, your claim for COVID-19 treatment will be rejected. Also, some policies do not cover home care expenses and pre or post hospitalization expenses like costs of diagnosis of COVID-19. Diseases not covered under the health insurance policy will be mentioned under the head exclusions or 'not covered.' If you raise a claim against an exclusion of your policy, it will be rejected. To avoid this situation, you must always read the policy document thoroughly. If you have a doubt or do not understand any part of your policy document, you should get in touch with the health insurance company and get it clarified.
  3. Exceeding time limit: In a health insurance policy, you are required to apply for reimbursement within a certain period of time. As for emergency admission, the time given is 24 hours after the patient has been admitted, and in other cases, it can change according to the type of policy you have opted for and the treatment being availed by you. If you don’t apply within the time specified, your claim can be rejected.
  4. Going beyond the sum insured: When you opt for a health insurance policy or a personal accident policy, there is an insured sum involved – whether it is a family floater or an individual health cover. Depending upon the chosen plan, the sum insured is the amount available to you or your family on a yearly basis. Assuming that you have utilized your entire sum for a particular year, your subsequent cashless claims will get rejected. However, if a part of your sum assured is still intact, the insurer might provide you with reimbursement at a later stage.
  5. Incorrect documentation: You need to follow the claim process diligently. There may be instances of incompletely/incorrectly filled application forms, lack of documentation, etc. Wrong information, suppression or misrepresentation of facts could also lead to rejection of the insurance policy. Partial or wrong disclosure of important details regarding age, medical history, occupation, income, etc. can easily lead to rejection of any insurance claim. It is advisable to get in touch with the insurance company to understand their health insurance claim process. This will reduce the chances of claim rejection.
Check list for avoiding rejection of medical insurance claims-
  • Fill up the proposal form yourself. Read all the terms and conditions carefully before submitting it. If any doubt, seek to clarify them from your insurer or agent.
  • Never ignore the exclusion list. It has all the situations and cases that are not covered under the claim policy according to the guidelines given by IRDA.
  • Be transparent about any pre-existing medical conditions and don’t hide it from your medical insurer. Get medical tests done if required and submit the report to your medical insurer.
  • For smooth claim settlement, it is important to intimate insurer about your hospitalization along with doctor’s prescription, hospital, and medical bills immediately or within stipulated time.
  • Renewing the health insurance policy within the time frame will help you avoid any inconvenience at the time of claiming. Though a 15-day grace period is provided by the insurer, it is important for one to renew their policy beforehand.
  • You must furnish all your bills from diagnosis to hospitalization, surgery, medicines, and doctor’s prescriptions to your insurer for timely claim settlement, failure of which results in claim rejection.
  • You are entitled to get the claim only when you are hospitalized in the network hospitals. Network hospitals are the pre-approved hospitals that have tie-ups with insurance companies.
It can be easily concluded that in order to avoid claim rejection, you should have a good understanding of your health insurance policy, ideally from the time of its purchase.

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