4 Reasons Why Your Health Insurance Claim Could be Rejected

Many of us have the habit of ignoring the fine print of a health insurance policy. This happens due to lack of seriousness and awareness of the consequences. Your laxity towards health insurance can get your claim rejected. This might sound less severe for those who don’t really understand the gravity of the situation. However, the people, whose claims were denied, would find the experience quite exhaustive and punitive.

So, it is crucial to know the reasons for which a claim can be rejected. At the same time, it is also important to understand preventive measures. There is a popular saying that “prevention is better than cure”. Similarly, in the insurance sector, it is better to avoid rejection than taking the remedial measures later on.

An insurance company can entertain your claim post rejection, provided you are able to convince the insurer that your claim is genuine. However, you first need to know why it was rejected and then take corrective measures. There are many reasons for denying your claim. These could be due to getting admitted to a non-network hospital, ignoring exclusions, etc. So, let us elaborate on the 4 reasons because of which your claim can be rejected.

1. Going beyond the Sum Insured

Have you heard of something called 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.

2. Ignoring the exclusions

There are several diseases for which coverage is not there in most of the health insurance plans. These are specifically mentioned in the policies as being ‘not covered’. These are essentially diseases for which you can’t file a claim and are generally referred to as exclusions. However, if certain plans or policies provide coverage for any such disease, then a waiting period will be there for the same. So, if you file a cashless claim for one such disease/medical condition that is excluded, then rejection is obvious.

3. Suppression, misrepresentation of facts

Some common causes for claims being rejected are non-disclosures, partial disclosures and wrong disclosures of important details such as age, nature of occupation, income, current insurance plans, major ailments or pre-existing medical 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.

4. Exceeding the 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.

 

It can be easily concluded that in order to avoid cashless claim rejection, you should have a good understanding of your health insurance policy, ideally from the time of its purchase. Then, you need to compare health insurance plans online to understand what is on offer and choose a policy that best meets your requirements. It is also pertinent to maintain a record of all your documents – pre and post hospitalization expenses, hospitalization records, diagnostic tests, discharge summary, investigation reports, etc. These documents can be extremely crucial if your insurer needs clarifications.

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