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Health Insurance Claim Rejection – Reasons and Prevention | 4036


Health Insurance Claim Rejection – Reasons and Prevention

WhatsApp Image 2023 08 07 at 9.22.16 PM

Medical emergencies occur out of the blue, and that too beyond one’s control. We may not be capable of preventing something adverse from taking place but are always in a state to handle what is feasible for us.

One of the best ways to ensure peace of mind in times of medical emergencies such as sudden illness or an accident is health insurance. Protection against multiple diseases and financial security are what one expects from their health insurance policy. At such times, one thinks of making the most of their ideal health insurance policy and dealing with the medical emergency without losing their savings in one go. But, what if the health insurance claim gets rejected?

New to the concept of health insurance claim rejection? Well, cases of health insurance claim rejection are common. As far as the reasons are concerned, there are many, which remain unexplored by most of the policyholders.

If you do not want to be one on the list of policyholders with rejected health insurance claims, here’s what you need to know-

Common Reasons Behind Health Insurance Claim Rejection:

  • Incorrect Information

When it comes to filling the application form, the details provided should be correct by all means. Wrong information or not filling the form properly in regards to the medical history are the reasons which lead to claim rejection as the insurer ultimately finds out the discrepancy. Not filling the form on their own or wrong information are the most common reasons behind health insurance claim rejection.

  • Pre-existing Disease

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. This, in turn, ends up being against them, as the insurers reject the claim based on non-disclosure of pre-existing diseases.

  • Lapse of Policy

Missing the premium date and not renewing the policy is also one of the key causes behind the claim rejection. It’s simple! If the policy is not active, the insurers do not settle the claim.

  • Late Intimation to Insurer

​Any delay in informing the insurer about hospitalisation may lead to the rejection of the claim. Policyholders who forget to inform their insurer within 24 to 48 hours of hospitalisation have no other option, but to deal with the claim rejection.

The reasons for rejection of health insurance policy may not be multifold, however, they are significant. It is important for one to be aware of the aforementioned reasons so that they can avoid distress at the last minute.

With that said, do you want to know what all you can do to avoid giving the insurers a reason for rejection in the first place? Well, check the list of steps to follow!

How to Prevent Claim Rejection?

  • First and foremost, keep in mind to go through all the policy wordings in addition to terms and conditions in a detailed manner. Being unaware of exclusions, deductibles, and claim process,es and other critical details will end up getting you confused or regretting the decision of investing in the wrong policy.
  • The best thing you can do to avoid the insurance claim rejected status is to fill up the form yourself and in case of any doubts, take the help of the insurer or agent. Don’t get the form filled by anyone else, other than yourself. Double-checking the insurance claim for accuracy is what you should also practice.
  • Giving correct information regarding medical condition is something that you should do without giving a second thought, if you want to prevent claim rejection at a point when you need the medical help the most.
  • One must not forget to make copies of all the documents they provide with the claim form for the health insurance policyBy doing so, it will be easy for the policyholder to provide TPA with the reference, in case the need arises in the future.
  • Providing all medical records to the TPA or Third Party Administrator is an essential element to keep in mind. If it is the case of post-hospitalisation costs incurred, providing the details and submission must be carried out within a span of 90 days from the hospitalisation date.
  • 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.
  • For planned hospitalisation, it’s better to look for the insurer’s approval in advance. However, in case of a medical emergency, one can proceed with the treatment and inform the insurer within 2 or 3 days of hospitalisation.

When their health claim insurance gets rejected, many insured customers file escalations against the health insurance company. This is definitely not the ideal way to deal with the situation.

As a matter of fact, the best possible way to handle things in such a scenario is to look for reasons for rejection in the first place. Later, one should think of the best way to deal with claim rejection in accordance with the reason, and of course, the assistance of TPA, licensed medical practitioner, or an ombudsman as per the requirement.


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