Many people assume that health insurance will cover all treatment costs, but when a claim is rejected, it can lead to frustration and confusion.
While it may seem like insurance companies reject claims on purpose, that’s not always the case. In most situations, claim rejections can be avoided with a little attention.
Let’s explore the common reasons for claim rejections and how to prevent them.
Non-Disclosure of Pre-existing Conditions
Health insurance operates on the principle of ‘Utmost Good Faith,’ meaning both the policyholder and the insurance company must share honest information.
Some people fail to disclose pre-existing conditions like diabetes, high blood pressure, or heart issues. This can lead to claim rejections.
How to avoid this: Always disclose your complete medical history when purchasing a policy, even if the conditions seem minor. This ensures your claims will be protected.
Not Reading Policy Terms Carefully
Many people skip reading the fine print of their policy when buying it.
Later, they may discover that certain treatments are not covered or that a waiting period applies (for surgeries like hernia or cataracts, for example).
How to avoid this: Take the time to read the full policy and ask questions if something isn’t clear. This will help you understand the coverage and exclusions.
Failure to Renew the Policy on Time
If you miss your premium payment, your insurance policy may lapse, and any claims made during that time can be rejected. Forgetting the due date for premium payments is a common issue.
How to avoid this: Set up auto-pay for your premiums and set reminders to ensure timely payments and avoid policy lapses.
Providing Incorrect or Incomplete Documents
Missing or incomplete documents can cause delays or rejection of your claim. Some people forget to keep hospital bills, medical reports, or doctor’s prescriptions, which are required for claims.
How to avoid this: Keep all medical documents organized, including hospital bills and discharge summaries. Submit all required documents to the insurance company promptly.
Treatment Not Covered by the Policy
Every health insurance policy has specific inclusions and exclusions. Treatments like cosmetic surgeries, dental care, and fertility treatments are usually not covered. If you claim for these, your request may be denied.
How to avoid this: Carefully review the ‘Inclusions’ and ‘Exclusions’ sections of your policy so you know what is covered and what is not.
No Pre-Approval for Cashless Claims
For planned surgeries or treatments, you need to inform the insurance company in advance to get pre-approval for cashless claims. Failing to do so may result in claim rejection.
How to avoid this: Always inform your insurer ahead of time for planned treatments and secure the necessary approvals for cashless claims.
What to Do if Your Health Insurance Claim is Rejected?
Health insurance provides financial protection, but it’s crucial to follow the necessary steps to ensure your claim is not rejected.
Always provide accurate information, read the terms of your policy, renew it on time, and keep all documents organized.
If your claim is still rejected, request clarification from the insurance company. If you are not satisfied with the response, you can file a complaint with the Insurance Ombudsman.
