Why are Health Insurance Claims Rejected for Senior Citizens?

Health insurance claim rejections for senior citizens mean more financial strain, emotional stress and even challenges in treatment care. A senior citizen health insurance claim can be rejected for many reasons, non-disclosure of pre-existing health conditions and incomplete documentation being the most common ones. Understanding the top reasons for which an insurer can deny a claim for a senior citizen health policy can better prepare you for the time when you need to file a claim.

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      Top 9 Health Insurance Claim Rejection Reasons for Senior Citizens

      Here are the most common reasons why insurers may reject health insurance claims filed by senior citizens:

      1. Non-Disclosure of Pre-Existing Diseases

        When buying health insurance, applicants are required to disclose all existing medical conditions and treatment history. If an insurer finds that a pre-existing disease, such asdiabetes, heart conditions, thyroid disorder, or hypertension, was not disclosed at the time of policy purchase, it may lead to claim rejection on the basis of misrepresentation or non-disclosure of a PED. Therefore, it is important to provide complete and accurate medical information when filling out the proposal form.

      2. Claim Raised During the Waiting Period

        Most senior citizen health insurance plans have waiting periods for pre-existing diseases and specific illnesses/ treatments. During this period, the insurer does not cover expenses related to the listed medical conditions. As a result, the claims for illnesses or treatments that fall within the applicable waiting period are rejected.

      3. Treatment Not Covered Under the Policy

        Like any other policy, your senior citizen health insurance policy comes with a defined list of inclusions & exclusions that help in determining the scope of coverage. If a claim is raised for a treatment, procedure, or medical condition that is specifically excluded from the coverage, the insurer rejects it.

      4. Exhaustion of Sum Insured

        The sum insured (SI) is the maximum amount an insurer will pay for covered medical expenses during the policy duration. If this limit has already been exhausted or there is insufficient sum insured for the subsequent claim, it shall not be approved. This is particularly important for senior citizens, who may require multiple treatments or hospitalisations within a policy year.

      5. Policy Lapse Due to Non-Renewal

        Health insurance coverage remains active only when the policy is renewed on time by paying the premium. If a policy lapses due to non-renewal, its coverage benefits also cease, and medical expenses incurred during that inactive period are not covered by the insurer.

      6. Incomplete or Incorrect Documentation

        The insurer needs documents like duly filled claim forms, original hospital bills, discharge summary, pharmacy bills, prescriptions and diagnostic reports to process claims. These documents help them verify the treatment received, medical necessity, and admissibility of the claim. If any of the required documents are missing or contain incorrect information, it can lead to claim rejection.

      7. Delay in Claim Intimation

        Most health insurance companies require the policyholder or their family member to notify about planned or emergency hospitalisation within a specified time. It helps them initiate the claim process and verify the treatment details. If it is not informed within the prescribed period, it may affect the claim assessment process and, in certain cases, result in claim rejection.

      8. Hospitalisation Not Meeting Policy Conditions

        Health insurance policies may specify certain conditions that must be met for claim approval. For instance, some treatments may require a minimum hospitalisation duration, while others may be covered only under specific circumstances. If the treatment or hospitalisation does not meet the eligibility criteria mentioned in the policy terms and conditions, it results in claim rejection.

      9. Fraudulent or Misleading Claims

        The insurance provider carefully assesses every claim before approving it. Claims supported by forged documents, altered medical records, inflated hospital bills, or inaccurate information are considered fraudulent. Such practices violate the terms and conditions of the policy and lead to claim rejection or even policy cancellation.

      Wrapping it Up!

      Since claim settlement depends on the policy terms and conditions, it is important to understand the coverage details and claim requirements beforehand. This helps senior citizens avoid common health insurance mistakes, thereby reducing their chances of claim rejection.

      Senior Citizens Health Insurance Claim Rejection Reasons: FAQs

      • Q. What are common reasons for claim rejections for senior citizens?

        Ans: Non-disclosure of pre-existing diseases, claims raised during the waiting period, policy exclusions, incomplete documents, delayed claim intimation, exhaustion of sum insurance, and policy lapse are the main reasons why a senior citizen health insurance claim is commonly rejected.
      • Q. What deductions can senior citizens claim?

        Ans: Senior citizens can claim tax benefits of up to ₹50,000 on health insurance premiums paid under Section 80D of the Income Tax Act. If they do not have active health insurance, they can claim medical expenses up to ₹50,000 incurred on their healthcare.
      • Q. What should you do if the insurer rejects your health insurance claim?

        Ans: First, understand the rejection reason, submit any additional documents if required, and contact the insurer's grievance cell. You can also connect with the insurance ombudsman if the issue remains unresolved.
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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.

      *₹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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