Can Health Insurance Claims Be Denied?

If we add the rising medical costs to this equation, the result only states the obvious – disaster! There is only one hope of battling out the highly probable medical costs that would befall us and that hope is a health insurance policy.

Perhaps, people have imagined the aftermath of a medical complication and that is why awareness of a health insurance policy is very high. The benefits of from a health insurance claim should compensate the substantial hospital bills accrued in the event of a medical emergency and as such becomes the lifeline of many individuals.

All of us invest in a good health insurance plan thinking it to compensate us whenever any claim falls. Is this thinking correct?

It may sound like bursting your bubble, but, your health insurance claim might be denied. Though the insurance company strives to fulfill the claims raised, there are certain instances which may result in a denial of claim settlement.

Reasons For Denial of Health Insurance Claim Settlement:

Misrepresentation or non-disclosure of material facts:

Though we blame the insurer if the health insurance claim is denied, do we ever blame ourselves? A health insurance policy is issued on the understanding that the proposer has stated all his required details truthfully and correctly in the proposal form. This is in compliance to the Principle of Utmost Good Faith which is the basis of all insurance contracts. Based on your stated facts, underwriting is done by which the insurer evaluates the risk you present. If you hide important information or lie about any medical condition you suffer from, you are in a diabolical position. In case of a claim, the insurer determines the cause of the claim and if it is discovered that the claim arose because you hid or lied about an important fact, the company has the authority to reject your claim.

Incorrect health insurance claim procedure:

The insurance provider prescribes certain steps which the policyholder is required to follow when making a claim. Informing the insurer of the emergency, seeking treatment in a recognized hospital, filling up the required claim form, attaching all the relevant bills and reports are some of the required things to do for making a claim. If your claim filing is improper or incorrect, your claim stands to be denied

Health insurance claims for permanent exclusions :

Every health insurance plan has an exclusion list, incidences which are excluded from the scope of coverage. These are the permanent exclusions and any claim made in respect of these excluded instances would be denied.

Health insurance claims for temporary exclusions:

Pre-existing ailments have a waiting period and there are other ailments which are covered only after a prescribed waiting period. Claims raised for such exclusions which have a waiting period during the waiting period would be denied

Claims on lapsed policies:

If you delay in paying the premium beyond the due date, the policy will lapse. A lapsed policy pays no claim so, even if it has been 2 or 4 days since a lapse, your claim would be denied.

How can you avoid health Claim Rejection?

Full disclosure

Yes, stating every personal detail asked, even if it is unfavorable is in your interests. It may increase your premium outgo if you have any existing ailment, but you would be ensured of your claims to be honored.

Following the claim procedure

After you buy the plan, you should be fully conversant in the steps to be followed for raising a valid claim. Seek the help of your broker if needed because the broker can guide you properly.

Renew your plan every year

Though you might not face a claim as soon as you buy a health plan, someday you would. When disaster strikes, you need a valid plan to pay the related expenses. You should, thus, renew your plan every year to ensure a continued coverage.

So, now you know why your claim can be rejected and how you can avoid it. Be aware and follow the guidelines to ensure that your health insurance claims get honored.

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Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in

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*We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30- minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881.

*Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. Policybazaar does not provide any medical or surgical advice or diagnosis and is not responsible for your interactions / treatment by a medical practitioner/hospital. Please consult a registered medical practitioner for any medical or surgical advice. The Information that you obtain or receive from Policybazaar, and its employees, or otherwise on the Website is for informational purposes only. As per the Insurance guidelines, you are allowed to cancel the policy with-in 30 days from the date of Issuance of policy.This option is available incase of policies with a term of one year or more.

*All the health insurance plans cover hospitalization expenses including COVID-19 treatment cover up to the specified limits. You can also buy specific COVID-19 health insurance policies such as Corona Kavach Policy and Corona Rakshak policy.

**All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws. GST Exemptions depend on fulfilment of qualification criteria and submission of relevant documents.

*₹1748/month is the starting price for a 1 crore health insurance for an 18-year-old male, with no pre-existing diseases. Discount on renewal premium is subject to the number of wellness points earned in the health insurance policy. For more details about the plans, please read the sale brochure carefully to get upto 100% discount on renewal premium.

*₹400/month is the starting price for ₹ 5 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

*₹541/month is the starting price for ₹ 10 lakh Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

*₹762/month is the starting price for ₹ 1 Crore Health insurance for a 30 year old male & 29 years old female, living in Delhi with no pre-existing diseases

*₹243/month(₹ 8/day) is the starting price for a 5 lakh health insurance for a 20-year-old male, non-smoker, living in Bengaluru with no pre-existing diseases

*₹2020/month is the starting price for ₹ 1 Cr Health insurance for a 50 year old male & 50 years old female, living in Bangalore with no pre-existing diseases rounded off to nearest 10.

*₹390/month (₹13 per day) is starting price for 1 cr. Health insurance for 25 years old male, with pre-existing diseases, residing from tier 1 city rounded off to the nearest 10.

*No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.

*The values taken for effective cost calculation are indicative values and may change as per the selected plan.

*Coverage upto double the amount of Sum Insured is available on certain covers for a minimum plan of Rs. 5 Lakh on the first claim only to an individual of upto 45 years of age with no pre-existing diseases. The benefit is available with or without extra cost depending on the plan chosen.

*Coverage of pre-existing diseases is provided by insurer as per their underwriting policy.

*The scope of coverage may vary from plan to plan.

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Tax Benefits are subject to changes in tax laws. GST Exemption depends on fulfilment of qualification criteria and submission of relevant documents as required by the insurers. For more details on risk factors, terms and conditions, please read the sales brochure and applicable rules and regulation carefully before concluding a sale.

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