We all know that health insurance is very important because medical expenses can run into lakhs and without an insurance cover one may have to dip into one’s savings. However, there are many reasons why your health insurance policy may be rejected. Let us look at the reason why your policy may be rejected and what you should do in case of a rejection.
Why Your Health Insurance Policy May Be Rejected
When it comes to insurance the process is a bit taxing, but it is also needed to ensure that accurate claims are processed. “One of the biggest reasons why claims get rejected is due to incomplete information. The biggest issue I believe is understanding the terms and conditions of the policy. To ensure health insurance claims are accepted, policyholders must thoroughly understand their policy terms,” says Sidak Singh, Co-founder, Care.fi, a fin-health-tech platform.
Understand the nuances and the fine print. For example, if there is a waiting period of two years but you want to claim it before then maybe your claim will get rejected. The leading reasons for health insurance claim rejection in India from October 2022 to February 2023 were primarily due to policy terms and conditions not being met at 36 percent.
To help streamline the process patients can also work with hospitals to streamline the documentation. “Ensure with the TPA dear that all the documents are maintained and accurate. Ensure that the hospitals also follow compliance as per the insurer. They can also help with queries and coordination with insurers when required for a quick turnaround time,” says Singh.
Besides this, the non-disclosure of all relevant medical information also leads to claim rejection. Failure to meet policy conditions, such as waiting periods, or withholding details like pre-existing conditions (e.g., hypertension, heart issues etc) , can lead to claim rejection. Submitting accurate and complete documentation is essential, and any queries from the insurer must be promptly addressed to avoid rejection.
In addition to this, sometimes there is also a lack of pre-authorization. Some procedures require prior approval from the insurance provider. So, if that is not obtained then it can lead to rejection. “It is important for the policy holders to pay attention to the above-mentioned points and proceed accordingly. In addition to these above-mentioned points, they can also ensure that the insurance company is notified of the claim in time,” says Singh. For example, if you are hospitalized due to an emergency, you should notify the insurance company within 24 hours.
Insurance providers stick closely to their policies rules to avoid fraud and manage costs. They need to make sure claims meet the policy’s terms, like waiting periods or specific conditions. Therefore, the health insurance claims often fax strict denials. To avoid the same, policy holders need to take care of documentation, terms and conditions and disclosure.
What To Do If Your Claim Is Rejected
The first thing you must do is review the rejection letter thoroughly to understand the reasons for denial. “Typically, gaps such as non-disclosure of information in the policy document, exclusions, lapsed policy, incomplete or incorrect claim details, or delay in filling lead to claim rejection. This makes it important to understand the cause and prepare for the next steps accordingly,” says Shilpa Arora, the Co-Founder and Chief Operating Officer (COO) of Insurance Samadhan, a platform for resolution of insurance complaints.
After the review, if you find your claim was rejected unjustly, you should gather relevant documents that could support your stance. At such a time, you could benefit from consulting an industry expert, whose expertise on claims denials, delays, or short settlements can help you understand the reason behind rejection and appeal the decision.
In case of unfair rejection, you can contact the Grievance cell of the insurance provider to discuss the gap and appeal to reconsider the decision or resubmit the claim. “However, you must follow the appeal process laid down by the insurer to avoid further misunderstanding. I also recommend that you offer additional evidence or information to support your renewed claim. In addition, make sure to keep track of all communications and follow up with the insurance provider to streamline the process better,” says Arora.
If the insurance company does not entertain your appeal and rejects the claim again, you can raise the concern to Bima Bharosa (IRDAI complaint portal). If you receive a denial from Bima Bharosa then you must consider contacting the Insurance Ombudsman within a year of the rejection to seek redressal. The last option is filing the complaint in the court.
