Top 8 Reasons for Health Insurance Claim Rejection

 

Health insurance is a security net for your family that helps you in covering medical expenses that may arise due to hospitalization, illnesses, or injuries. It is a promise of your insurer to safeguard you financially in case of any medical emergency, but there could be reasons that may result in claim rejection. But worry not. By avoiding some of the common mistakes, you can ensure a smoother and quicker claim processing for your health insurance policy.

 

Pre-Existing Conditions Not Disclosed

At the time of purchasing a health insurance policy, your insurer will inquire about your medical history to ascertain if you have any pre-existing medical condition like diabetes, hypertension, asthma, etc. It is important to disclose such health conditions to avoid claim rejection for such problems.

How to Avoid This:

Always be honest while filling out your insurance application. Even if disclosing a condition increases the premium and elongates the waiting period, it ensures transparency and claim validity.

 

Claim During Waiting Period

Most health insurance policies have a waiting period before you can actually use the policy benefits. If you have a pre-existing health condition, then the waiting period will be 4 years. During this duration, if any medical exigency occurs, your claim may get rejected.

How to Avoid This:

Make sure to understand the policy terms and conditions completely and plan your medical expenditure as per your waiting period.

 

Treatment Not Covered Under Policy

Health insurance policies have certain inclusions and exclusions that define the scope of coverage. Be mindful to choose your health insurance coverage carefully to cover your specific healthcare needs.

How to Avoid This:

Consult your insurance provider to know the coverage of your health insurance policy and read your policy document thoroughly.

 

Exceeding the Sum Insured

Every health insurance policy has a pre-defined sum insured, which is the maximum amount for which you will be covered by your health insurance provider. If the medical bills exceed the limit of sum insured, then you will have to pay the remaining amount from your pocket.

How to Avoid This:

Make sure to choose the optimal sum insured considering your age, medical history, healthcare needs, and rising medical costs.

 

Incomplete or Incorrect Documentation

While submitting a claim, you need to make sure that all the required documents are available along with proofs (if any). Incomplete documentation can lead to delay or even claim rejection.

How to Avoid This:

Double-check all the forms, information, and documents before submitting them.

 

Delay in Filing the Claim

If you are opting for a reimbursement claim, then you must file the claim within the specific timelines defined by your insurance provider. Delaying the process can lead to possible rejection of your health insurance claim.

How to Avoid This:

File your claim as soon as possible after treatment. Keep track of deadlines mentioned in your policy.

 

Policy Lapses Due to Non-Payment of Premiums

Non-payment of health insurance premium on time can lead to policy lapse, which means you will not be able to avail yourself of any coverage from your health insurance policy. Any claim made after your policy has lapsed will be rejected.

How to Avoid This:

Make timely payments towards your health insurance premium to avoid hassles.

 

Violation of Policy Terms

Every health insurance provider has specific terms and conditions that you must follow, non-compliance of which can lead to policy cancellation or claim rejection in the future.

How to Avoid This:

Understand and clarify your doubts thoroughly with your health insurance provider to make an informed decision.