Reasons for Health Insurance Claims Rejection

Policyholders often find their health insurance claims getting rejected. This means that policyholders would have to bear the medical bills accrued since hospitalization and medical treatment. However, it does not mean that health insurance companies look for ways to reject or deny health insurance claims made by their policyholders.

Common Reasons for Denial of Health Insurance Claims

Misrepresentation of health details or non-disclosure of pre-existing illnesses in the policy

Any and every kind of insurance is based on the Principle of Utmost Good Faith. This implies that the policy proposer must state all details regarding his health correctly. This is because the underwriting assesses the premium charges based on your risk profile. The insurance company before settling the claim finds out the cause of the claim made and the reason for treatment. On finding that the policyholder had been treated for some pre-existing disorder and had failed to mention the same while buying the policy, the insurer has the right to reject the claim.

Not adhering to the correct health insurance claims process

There is a certain set of procedures prescribed by each insurance company concerning the health insurance claim settlement process. This involves:-

1. Informing the insurance company prior to hospitalization about the forthcoming claim (in case of planned treatment)
2. Intimating the insurance company about the impending claim within 24 hours of hospitalization (in case of a medical emergency)
3. Taking the pre-authorization form from the insurance company or the concerned TPA before being admitted to hospital (in case of planned treatment)
4. Filling up the necessary claim form
5. Attaching all relevant bills and reports for making a claim (in case of seeking reimbursements on the claims made)

Incorrect details in the claim form

Filling the claim form incorrectly can also result in claim rejection.

Claims made on temporary exclusions

Every insurance company mandates a waiting period for certain pre-existing illnesses. This may range from two to four years. Also, the illnesses included in this list may vary. These pre-existing disorders are treated only after a prescribed waiting period. The insurance company would deny or reject any claim raised for treating a health problem excluded during the waiting period.

Claims made on permanent exclusions

Not all illnesses are covered under a health insurance scheme. Every health insurance company has an exclusion list containing lists of disorders or diseases excluded from the purview of treatment. These illnesses are termed “permanent exclusions” under the health insurance policy, and hence, any claim made towards their treatment would always stand rejected.

Claims made on lapsed policies

A lapsed health insurance policy document has no value. This means that any claim made on a lapsed policy will automatically be rejected.

How to Resolve Health Insurance Claims Rejection?

In most cases, claims get rejected because policyholders have either failed to submit all the necessary documents or had missed reading details published in the policy document. Once your health insurance claims have been rejected, it is important to follow certain necessary steps to avoid rejection again during the policy period. These include:-

1. Subsequent to claim rejection by the health insurance company citing erroneous details, it would be advisable to request the insurance company to correct the details. The correct details may be sent to the insurer or the TPA through an email.
2. The policyholder must keep a track of all details shared by the insurance company in the event of any electronic correspondence between the two. It is important to share with the TPA a record of all the correspondence.
3. In the event of claim rejection due to any document that had been left unfilled, then the policyholder must collect all the documents required and approach the insurance company within the stipulated time period. In the event of claim settlement through the TPA, it is important to submit the correctly filled documents with the TPA again.
4. If the claim had been rejected as the insurance company had found the medical treatment unnecessary, then it is important that the policyholder provides necessary medical data to prove why the treatment was important and could not be avoided. The policyholder can submit documents including medical opinion records or those pertaining to medical research. To ensure hassle-free claim settlement, the policyholder must write a formal letter to the insurance company along with necessary medical evidence to prove why accessing the treatment was important for health reasons.