Health Insurance 386 views January 15, 2022

Yes, they can, if you don’t follow the rules for getting a health insurance claim. Besides non-compliance, people mistakenly claim for something which they don’t have the right to. Health insurance companies come with a list of both inclusions and exclusions. So, if the disease or treatment you’re claiming for falls under the list of exclusions, rejection is obvious! Also, some put before insurers faulty claim requests to fulfill their malicious intentions.

Health Insurance

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So, scrutinizing the claim requests of claimants becomes a must-do thing for insurers. Only when your claim request meets the eligibility norms successfully does the insurer approve the same. Let’s check in detail the reasons for health insurance claim denial and avoid them for a hassle-free experience.

Let’s Have a Brief on Health Insurance First

Health insurance is a contract between you and the insurance company wherein the latter is liable to indemnify you against the financial losses caused due to medical emergencies. However, it will pay you for the covered illnesses and treatments only and up to the limit as specified in the policy contract. You can choose to have cashless treatment at the network hospitals of the company located nearby or elsewhere. Cashless means you won’t need to pay for the treatment as the insurance company will settle your medical bills directly with the network hospital.

Whereas, if the treatment happens at a hospital other than from the list of network providers, you will have a reimbursement option for you. In that, you’ll need to pay for your treatment first before the company would reimburse you the covered amount. Upon discharge, pay your bills, collect the necessary documents and submit the same to the insurance company for reimbursement. The insurance company will check your application thoroughly and approve the same after successful verification. A few days from approval, you’ll get the claim amount in your bank account.

Let’s Discuss the Possible Reasons for Health Insurance Claim Denial in Detail

The reasons, as briefed earlier, could be due to illegitimate claims as well as non-compliance to rules when claiming. Knowing the same beforehand will help you avoid getting into the terrible mental space that becomes the case with a claim rejection. More so when you’ve no savings and depend heavily on the financial support extended by the insurer.

Non-compliance to Health Insurance Claim Intimation Rules

Intimating the insurer about the health insurance claim and doing so within the prescribed time are two different things altogether. While reading the policy brochure, you could see the time within which you need to intimate the insurer about your claim. Cashless treatment at network hospitals can be either planned or of an emergency nature. You’ll need to intimate the insurer 2-3 days before the planned admission and within 24 hours of emergency admission. In contrast, one needs to intimate a reimbursement claim within 24 hours of admission. However, all these intimation norms can vary from one policy to another. In case you don’t comply with these norms, rejections can happen.

Non-compliance to Waiting Period Norms Can Also Lead to Claim Rejection

The waiting period, which is typical of health insurance policies, means the time for which you need to wait before the insurance company starts covering you against numerous health conditions. What’s interesting is that the waiting period norm is not uniform across health conditions. There will be an initial waiting period of 30 days from the date of policy commencement, except for accidental injuries. Besides, if you have a disease or condition before purchasing a health insurance plan, you’ll need to wait for up to four years to get covered for the same. Similarly, maternity insurance plans will have a waiting period of nine months. In case you claim during that period, the insurance company will not honour your request.

Health Insurance Claim Made for Outright Exclusions

As told above, insurance companies won’t honour claims for expenses listed under ‘Exclusions’ in the policy document. For example, accidental injuries don’t have a waiting period. But before approving the claim, the insurer checks whether the accident was due to you driving under the influence of alcohol. If that’s proven in its investigation, your claim won’t go through successfully. Similarly, the insurer won’t cover a few more expenses. We’ve listed some injuries or diseases which insurers don’t cover generally.

  • Injuries due to participation in adventure sports
  • Injuries due to breach of law
  • War-related injuries
  • Congenital external diseases, defects, anomalies
  • Sexually transmitted diseases
  • Alcoholism or drug treatment

Hospitalization Expenses Not Covered Fully in Some Cases

In today’s COVID times, gloves, masks, PPE kits and other equipment are extensively used to treat patients even if they’re not affected by this virus. Most health insurance plans don’t cover the cost of such equipment. So, despite health insurance coverage, you’ll need to pay that part of your hospitalization. It’s important to have coverage for such equipment that has led to a 30-40% rise in the overall hospitalization cost across India. They might come as a rider to the base plan and add to your premium. But given how steeply they add to your hospital bills, it makes sense to buy a rider.

Other than the equipment, insurance plans can come with a certain sub-limit on room rent. In case you’ve bought such a plan, you’ll need to pay besides the covered amount. It works by covering up to the sub-limit mentioned in your policy. The moment the actual cost exceeds the prescribed limit, you’ll need to bear the extra amount. Sub-limit can be on room rent, disease, etc.

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