Decoding Insurance

5 Reasons Why Your Health Insurance Claim Could be Rejected?

Owing to the COVID-19 pandemic and the advancement in medical technology, the treatment cost at private hospitals in all major cities across the country has become more expensive. Due to these skyrocketing medical costs, you may not always be able to get the best treatment. Furthermore, in case of a medical emergency, you may even be forced to dip into your savings to get the treatment done.

As we all are aware, medical emergencies come unannounced, one can always rely on an adequate health insurance plan. It will ensure that you get appropriate treatment promptly, irrespective of your financial condition.  Further, purchasing health insurance is no longer a choice, but rather a necessity.  Investing in the right health plan will help you cover all expenses related to medical tests, doctor’s fees, cost of the ambulance, hospitalization charges, and post-hospitalization charges as well. 


However, many of us have a bad habit of skipping over the terms and conditions in our health insurance policies.  This indifference towards your health insurance could result in your claim being denied and can put you in a financially difficult situation. Thus, it’s crucial to know the reasons for which your claim can be rejected. 


One of the most common mistakes made by the policyholders is not disclosing pre-existing conditions. Many people avoid disclosing their health conditions because they assume their insurers will refuse to offer the coverage. However, what they don’t know is that if, in an emergency, they are hospitalized due to a health condition that they suffered from at the time of buying the policy, the insurance company has the right to deny the claim, which would result in a financially difficult situation. As a result, being honest can only benefit you because it will help you in finding a better insurance plan that meets your needs and covers you in case of an emergency.

2.  Take note of Sub-limits 

Taking note of clauses like sub-limits is one of the most important things to consider when choosing health insurance. Under a sub-limit clause, the insurer places a limit or a cap on the policyholder's medical expenses for a specific medical procedure or hospital’s room rent. For instance, if there’s a 50% sub-limit cap on knee surgery and your sum insured is Rs 5 lakhs, you won’t be able to claim more than 2.5 lakhs because of this cap.  Considering this, you might find that the claim has been rejected partly, because of this clause. Thus, it is important to be aware of all the clauses before you invest in the policy. 

3.  Duration of the treatment 

If you or a member of your family is not hospitalized for a minimum of 24 hours and is discharged early from the hospital, your policy claim can get rejected.


There are various conditions for which most health insurance plans do not provide coverage. These are clearly specified as being "not covered" in the policies. These are treatments for which you are unable to register a claim and are referred to as exclusions. One has to bear these expenses from his/her own pocket. These exclusions include cosmetic treatments, therapies, self-inflicted injuries, etc. Thus, If you submit a cashless claim for a treatment or medical condition that isn't covered, your claim will almost certainly be denied.

5. Making a claim in the waiting period

Health insurance companies have an initial waiting period to activate the coverage, typically 15 to 30 days and a waiting period for a pre-existing condition generally 2 to 4 years.  Which means during this time period a person cannot make a claim. The duration of the waiting period varies by plan and claim type. Thus, if the insurer raises a claim early for a condition that requires a waiting period, there's a good probability it'll be rejected.

To sum up, policyholders must give the insurer complete, accurate, and up-to-date information. If a condition is not disclosed at the time of buying insurance, the claims will be rejected subsequently. Additionally,  it's essential to read the policy's terms and conditions thoroughly so that any circumstances where claims can be rejected are avoided.


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