10 Reasons Why Your Health Insurance Claim Can Get Rejected

Health insurance plans add a layer of invisible protection against rising medical inflation and unforeseen emergencies. However, your health insurance claims can also get rejected at the very last moment. It not only leads to unnecessary stress but also poses a financial burden on the person admitted to the hospital. To avoid such situations, check out the most common reasons why your health insurance claim can get rejected.

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      10 Common Reasons for Health Insurance Claim Rejection

      There are several reasons why the insurance provider 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 and maternity waiting period to a pre-existing disease waiting period. 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. A person buying health insurance is supposed to declare all pre-existing diseases in the proposal form during policy purchase. If the diseases are not disclosed, and the insurer discovers them later, they will have the right to reject your claim.

      4. Lapsed Health Insurance

        A health insurance policy lapse if the premium is not paid on time. As a result, the insurer is not liable to provide medical coverage to the people covered in a lapsed policy. 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 within the stipulated time to file a claim. If the insured forgets to intimate the claim within the stipulated time, the insurance provider will deny your claim request.

      6. Missing Documents During Claim Submission

        When filing a reimbursement claim, the policyholder should submit the required documents to the insurer 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 a sum insured limit for a policy year. Repeated hospitalization, especially for people with severe health issues, can lead to complete exhaustion of the sum insured amount. In such a situation, the insurer has the right to reject your claim.

      8. Changes in Policy Terms & Benefits

        Insurance companies may sometimes modify the policy terms and conditions, such as the coverage benefits, premiums, etc. Therefore, if your policy has been modified and your coverage has been amended, then your claim may 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 the medical records. As a result, the insurance provider may consider the claim duplicitous and reject it.

      10. Insurer/Third-Party Assessment was Not Completed

        Claims for some medical procedures and treatments can be done only after a pre-authorization has been received from the health insurance company or Third Party Administrator (TPA). In such cases, the insured has to file a pre-authorization request with their health insurance provider or TPA. But if this process is not followed, your claim settlement can be halted, ultimately, leading to rejection.

      You May Also Read - Health Insurance Portability

      10 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. 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.

      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. Cashless Treatments at Empanelled Hospitals

        To avail cashless treatment, make sure to get admitted to a network hospital of your insurance company.

      5. Declare Pre-existing Diseases During Purchase

        Make sure to declare any pre-existing disease of all the people covered under the policy at the time of buying.

      6. 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.

      Wrapping Up

      A health insurance plan protects you from financial and mental stress during medical emergencies. Getting your claim rejected at this time can be extremely stressful. But if you remember the common reasons for claim rejection and keep the above-mentioned tips in mind, you can prevent your claims from getting rejected.

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