10 Reasons Why Your Health Insurance Claim Can Get Rejected

10 Common Reasons for Health Insurance Claim Rejection

There are several reasons why an insurance company would reject a health insurance claim. Some of the most common reasons for claim rejection are as follows:

1. Incorrect Information on the Claim Form

   The basic reason for claim rejection is providing incorrect information on the claim form. To file a health insurance claim, you need to fill out the claim form with all the required details like your age, name, phone number, name of the illness, etc. If the details are not accurate, the insurer will reject your claim due to discrepancies.

2. Raising Claims During the Waiting Period

   Every health insurance plan comes with a waiting period during which you are not eligible to raise a claim. They may range from an initial waiting period of 30 days and a maternity waiting period of at least 3 months to a pre-existing disease (PED) waiting period of up to 3 years. If any claims are filed within the waiting period, they will be rejected.

3. Non-Disclosure of Pre-existing Diseases

   Another major reason for claim rejection is the non-disclosure of pre-existing diseases at the time of buying the policy. When you buy health insurance, you are supposed to declare all pre-existing diseases and previous surgeries in your proposal form. If these diseases/surgeries are not disclosed, and the insurer discovers them later, they will have the right to reject your claim.

4. Lapsed Health Insurance Policy

   A mediclaim policy can lapse if the premium is not paid on time. The insurer is not liable to provide medical coverage to you if your policy has lapsed. Thus, any claims filed using a lapsed policy will be rejected by the insurance company.

5. Delay in Claim Intimation

   Every insurer has a fixed deadline for claim intimation. It is essential to inform your insurer or its Third Party Administrator (TPA) about your hospitalization within the stipulated time to file a claim. If you forget to intimate the claim within the stipulated time, your insurance company will deny your claim request.

6. Missing Documents During Claim Submission

   When filing a reimbursement claim, you should submit the required documents to your insurer/TPA within the stipulated time for claim processing. If the documents submitted are insufficient or missing, it will lead to claim rejection.

7. Exhaustion of Sum Insured in Previous Claims

   Another reason for health insurance claim rejection is the exhaustion of the sum insured. Every policy has an annual sum insured limit. Repeated hospitalization, especially for people with severe health issues, can lead to complete exhaustion of the coverage amount. In such a situation, the insurer has the right to reject your claim.

8. Changes in Policy Terms & Benefits

   Health insurance companies may sometimes modify the policy terms and conditions, such as the coverage benefits, premiums, etc. If you file a claim for modified coverage, your claim can be rejected.

9. Incorrect Diagnosis of Illness

   Another important reason for claim rejection is the incorrect diagnosis of a disease. The wrong diagnosis on the claim form may not match your medical records. As a result, the insurance company may consider the claim as fraudulent and reject it.

10. Incomplete Insurer/Third-Party Assessment

    Health insurance claims for some medical procedures and treatments can be processed only after a pre-authorization has been received from the insurance company. In such cases, you have to first file a pre-authorization request with your insurer or TPA. But if this process is not followed, your claim settlement can be halted, ultimately leading to rejection.

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8 Tips to Avoid Rejection of Health Insurance Claims

Here are a few tips that you must keep in mind to prevent your health insurance claim from getting rejected:

1. Read the Policy Terms & Conditions Carefully

   Before purchasing health insurance, it is essential to carefully read all the policy terms & conditions and understand them clearly. In case of any confusion, you can reach out to the insurer's customer support team.

2. Provide Detailed and Accurate Medical Information

   Make sure to provide all your medical information accurately, including medical history, while filling out your claim form.

3. File Claims on Time

   Make sure to inform the customer support team of your insurance company about your hospitalization and submit the required medical documents within the specified time.

4. Declare Pre-existing Diseases During Purchase

   Make sure to declare the pre-existing diseases of all family members covered under your policy at the time of buying.

5. Check the Balance Sum Insured

   If you or your family members have filed multiple claims during the policy year, make sure to check the balance sum insured before filing another claim.

6. Check the Waiting Period Before Claims

   Make sure to check all waiting periods applicable to your policy to avoid filing a claim during this period.

7. Inform Timely for Cashless Treatments

   To avail cashless treatment at any hospital of your choice, make sure to inform your insurance company within 48 hours of an emergency hospitalization and at least 48 hours before a planned hospitalization.

8. Renew Your Policy on Time

   To prevent your policy from lapsing and your claim from getting rejected, make sure to renew your policy on time by paying the renewal premium before the due date.