A health insurance plan offers financial security against unforeseen medical emergencies. A few benefits of health insurance include coverage for hospitalisation, medications, critical illness, etc.
However, there are a few instances wherein your claim for online medical policy may be rejected. In such a situation, you must pay for the medical expenses out of your pocket and the insurer will not be liable to cover for your expenses.
This blog will discuss why your health insurance claim can be rejected and ways to prevent it.
Top 9 Reasons Health Insurance Claims are Denied and Ways to Overcome Them
Below are some reasons your health insurance claim might get rejected, along with effective prevention strategies.
1. Wrong Information on the Health Insurance Claim Form
When you raise a health insurance claim, you are required to fill out an application form. This claim application form requires you to fill out specific details such as the policyholder’s name, policy number, doctor’s name, the medical treatment involved, etc. Your health claim will likely be rejected if you enter the wrong details in any field.
First, ensure you fill in all the correct information to avoid this. Second, double-check all the details on the claim form, including personal information, medication, diagnosis, etc., before you submit it to your insurance company.
2. If You File a Claim Within the Waiting Period
Every health insurance plan comes with a certain waiting period, regardless of who your insurance provider is. Any claim raised during the waiting period will not be covered by your insurance company. Some waiting periods include:
- Maternity waiting period (2-4 years)
- Pre-existing waiting period (2-4 years)
- New policy waiting period (30 days)
- Critical illness waiting period (90 days)
Ensure you read your health insurance policy document carefully for details of the waiting period. This will help you understand when and how to raise a claim to avoid the risk of claim rejection.
3. Failure to Attach Essential Documents With the Claim
In case of reimbursement claim settlement, you must collect and submit medical reports, documents, discharge history, etc., to your insurance provider. In case of wrong or missing documents, your health insurance claim is highly likely rejected.
You must review your policy document and contact your insurance provider about all the required documents. You can list the necessary documents and cross-check them before you submit your claim form.
4. Lapsed Health Insurance Plan
A health insurance plan is only valid for a certain period(one year or multiple years). Once the policy term is over, the policy must be renewed, and the renewal amount must be paid. Failure to pay the renewal premium will result in your policy being lapsed. If you raise a claim under a lapsed health insurance policy, your insurance provider will reject the claim.
Therefore, make sure you know your health policy’s expiry date and pay to renew it on time, ensuring your policy stays active.
5. Failure to Inform The Insurance Provider on Time
Your cashless treatment claim can be rejected if you do not inform your insurance provider about hospitalisation within a specific timeframe. Therefore, in case of an emergency hospitalisation due to an unforeseen incident, inform your insurance provider within 24-48 hours of the hospitalisation, according to your health policy terms.
6. Raising a Claim for Benefits That Are Not Covered
Every health insurance policy does not cover some services or benefits. If you raise a claim for services that are not covered, your claim can be rejected. These services may include AYUSH treatment, Maternity claims, OPD (Outpatient Department) services, Dental treatment, etc.
Ensure you read your policy documents to understand what is covered and what is not. Additionally, check the extent of coverage and the associated terms and conditions.
7. Policy exclusions
Some procedures might be considered an exclusion by all insurance providers. Examples include plastic or cosmetic surgery, treatment for drug abuse or alcoholism, and treatment for a change of gender. A claim related to any of the policy exclusions will be rejected. Therefore, ensure you are aware of all the exclusions of your policy.
8. The Claim Amount Exceeds the Sum Insured
Every health policy has a specific sum insured. Suppose the claim amount exceeds the sum insured (usually happens when you raise multiple claims within a year). In that case, the insurance provider will only approve up to the remaining sum insured, while the rest will be rejected. To avoid this, you must upgrade to a higher coverage amount.
9. Change In Policy Terms And Conditions
If the insurance provider has updated terms and conditions and you are unaware of that, it can result in non-compliance, leading to claim rejection.
To Wrap It Up
A claim rejection can result in you paying out of your pocket for expensive medical bills. Follow all the strategies mentioned above to avoid healthcare claim rejection.
Moreover, while buying health insurance online, choose an insurance provider that offers a hassle-free and smooth claim settlement process. This will ensure that you navigate the claim process easily, limiting the risk of rejection.
