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Difference Between Claim Repudiated and Claim Rejected in Health Insurance
Health insurance claims are extremely important in getting financial support during an unforeseen medical emergency. However, insurance companies often reject or repudiate medical claims, confusing the policyholders. Even though both terms imply your claim will not be paid, they have a different meaning. Let us understand the key differences between a claim repudiated and a claim rejected.
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- Difference Between Claim Repudiated and Claim Rejected in Health Insurance
What is Claim Repudiation?
Claim repudiation in health insurance implies that your insurer has denied the claim after a thorough examination due to not meeting the terms and conditions of the policy. It happens when your claim is outside the scope of coverage, is fraudulent, is filed during the waiting period, or material facts have not been disclosed. It usually occurs after thorough assessment and documentation verification.
For example, if you file a claim for a cosmetic surgery, your claim will be repudiated as the procedure is not covered under health insurance.
What is Claim Rejection?
Claim rejection occurs when your health insurance company rejects your claim due to specific reasons related to the validity of the coverage. It usually happens in case of errors in claim forms, issues with the submitted documents, violation of policy terms or incorrect procedure followed. A claim rejection implies that the insurer did not process your claim for several reasons, such as incomplete paperwork, lapsed policy, or incorrect details.
For example, if you submit a claim with missing hospital bills or fill in the wrong policy number, the insurer can reject your claim immediately.
Key Differences Between Claim Repudiated vs Claim Rejected
The following table highlights the key differences between a claim repudiated and a claim rejected:
| Category | Claim Repudiation | Claim Rejection |
| Stage | Happens after a full investigation of the case | Happens at an early stage, even before evaluation |
| Reason | Due to not fulfilling policy terms and conditions, general exclusions, non-disclosures, etc. | Mostly due to technical issues, like lapsed policy, documentation errors, violation of terms and conditions, incorrect following of procedure, etc. |
| Claim Review | Fully and thoroughly reviewed | Not reviewed thoroughly |
| Scope of Resubmission | Not possible, unless challenged with strong evidence | Possible after rectifying errors as per the remarks by the insurer |
| Examples | Treatment not covered, pre-existing condition not disclosed, non-disclosure of pre-existing diseases, etc. | Missing documents, expired policy, incorrect procedure followed, violation of policy terms, etc. |
Common Reasons for Claim Repudiation
Some of the common reasons for a claim repudiation are given below:
- Non-Disclosures: Not disclosing your pre-existing diseases, medical history, etc., while buying your mediclaim insurance can lead to claim repudiation.
- Waiting Period: Your claim can also be repudiated if it is filed during the waiting period. For instance, most health plans do not cover pre-existing diseases (PED) until a waiting period of up to 3 years is served.
- General Exclusions: All health insurance policies have certain exclusions, like self-inflicted injury, sterility treatments, etc. Filing a claim for treatments falling under exclusions will be repudiated.
- Fraudulent Claims: If your insurer comes across any fraudulent activities, such as fake bills, forged signatures, or any other violations, your claim will be immediately repudiated.
- Policy Exhaustion: The claim will be repudiated if your policy has lapsed or you have used the entire sum insured.
How to Avoid Claim Repudiation?
You can avoid claim repudiation using the following tips:
- Read the Policy Documents Thoroughly: Try to understand what your health insurance covers, what are the waiting periods, clauses, and terms and conditions.
- Disclose All Medical Conditions: Make sure to disclose your pre-existing diseases, medical histories, previous surgeries, etc., to your insurance company at the time of buying the policy.
- Choose a Sufficient Coverage Amount: It is very important to choose a sufficient sum insured as per your medical history, budget, current medical costs in your city, etc. This will ensure that your claim is not repudiated due to insufficient funds.
- Do Not File Fraudulent Claims: Make sure to submit actual documents and provide correct details to avoid a fraudulent claim.
Common Reasons for Claim Rejection
Here are some common reasons for a claim rejection:
- Incomplete Claim Form/Documents: The most common reason for a claim rejection is submitting an incomplete claim form or missing documents.
- Policy Lapse: If your policy has lapsed while you are hospitalized, your claim will be rejected.
- Delay in Filing a Claim: All insurers have a deadline for policyholders to submit their claims. Your claim can be rejected if you miss the deadline.
- Incorrect Policy Details: Making any errors while filing your claim, like entering the wrong policy number, member ID number, wrong spellings, etc., can lead to a claim rejection.
How to Avoid Claim Rejection?
You can follow the tips mentioned below to avoid claim rejection:
- Submit Complete Documentation: You must always ensure to attach all the required documents, such as medical bills, doctor's prescriptions, discharge summary, test reports, etc., while submitting your claim.
- File the Claim on Time: You should not miss the deadline set by the insurer to file your health insurance claims.
- Ensure to Renew Your Policy Timely: Regularly renew your policy and track premium due dates to avoid a policy lapse.
- Verify All Details: Make sure the name, ID, hospital details, and diagnosis are accurate and always cross-check before submission to avoid any rejection.
FAQs
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Q1. What does a rejected claim mean?
Ans: A rejected claim means your insurer will not process the claim due to technical errors, incomplete documentation, policy lapse, or violation of terms & conditions. -
Q2. What is claim repudiation in insurance?
Ans: A claim repudiation in health insurance implies that your claim is not eligible and will not be paid after a thorough examination, as it does not fulfil the terms and conditions of the policy. -
Q3. Can insurance reject a claim?
Ans: Yes. An insurance company can reject your health insurance claim due to incomplete documents, errors in filing claims, violation of policy terms & conditions, policy lapse, etc. -
Q4. Who rejects a claim?
Ans: The claims team of the insurance company can reject your claim. -
Q5. What happens if my claim is rejected?
Ans: If your claim is rejected, you are not eligible to receive any payment from your insurer unless the issue is resolved or rectified. You can usually correct the error and resubmit the claim within the allowed time. -
Q6. What should I do if my claim is rejected?
Ans: If your claim is rejected, you can check the reason and either correct the mistake or submit the missing document to file your health insurance claim again. -
Q7. Can you correct a rejected claim?
Ans: Yes, most rejected claims can be corrected and resubmitted if it was due to documentation errors or incorrect policy details. -
Q8. Does repudiate mean reject?
Ans: No, a claim rejection is generally due to errors, such as incorrect or incomplete details. On the other hand, claim repudiation happens when a claim does not meet the policy terms after a thorough examination, like your medical treatment is not covered under the policy. -
Q9. How do I dispute a rejected claim?
Ans: You can dispute a rejected claim by writing a letter of appeal to your insurance company. -
Q10. How do I appeal a rejected claim?
Ans: You can contact your insurer, correct the issue that led to the claim rejection, and submit the claim again within a specific time. -
Q11. Can a claim be rejected after 3 years?
Ans: Yes. A health insurance claim can be rejected after 3 years due to policy lapse, incomplete documents, violation of policy terms & conditions, errors in filing claims, etc. -
Q12. What is the difference between rejected and reversed claims?
Ans: A rejected claim is denied before it is processed and is usually rejected at a very early stage. On the other hand, a reversed claim is when it was initially approved by the insurer but later cancelled due to errors or ineligibility. -
Q13. What is the difference between repudiation and cancellation?
Ans: Repudiation refers to denying a specific claim by the insurer, while cancellation refers to terminating the health insurance policy by the policyholder.
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