Top reasons your health insurance claim can get rejected & how to ensure a hassle free settlement

Buying a health insurance policy is one of the wisest things you can do for yourself and family. But what happens if the insurance claim which you are in dire need of to pay hospital bills is rejected by the insurance company. While the health insurer could be at fault for wrongly denying a claim, many a times, it is the mistake of the policyholder. Before you accuse the company, start with knowing the reason for claim denial. Let us examine the probable factors which may lead to claim rejection:

  • Waiting period: Every health insurance policy has a waiting period right from day one of buying the policy. During the stipulated period, if you claim for hospital bills, it will be rejected. If you have any pre-existing illness at the time of taking the policy, you will not be covered for a maximum period of the first 4 years. Some companies have shorter waiting periods depending upon the type of illness. Some illnesses are temporarily excluded and covered only after a certain number of years. In the case of a critical illness plan, any claim for an illness like cancer, stroke, etc., diagnosed within the first 90 days and death within 30 days following the diagnosis of the critical illness plan will be rejected.
  • Exclusions: If you claim for certain treatments like dental surgery, cosmetic surgery, infertility treatment, etc., it will be rejected as they are not covered in most health policies. These are called permanent exclusions.
  • Delay in policy renewal on time: If you fail to renew your policy on time, it will lapse and any claim during this period will not be entertained by the health insurer. Moreover, your waiting period will start afresh after the policy renewal.
  • Non-disclosure of important information: Some customers believe that concealing important health information could result in lower premium cost of the policy. Any pre-existing illness, past medical history, or any relevant information about health, if not disclosed but detected at a later stage during hospitalisation could land you in trouble. The health insurer reserves the right to reject your claim on the grounds of non-disclosure of material facts pertaining to health.
  • Incorrect personal details: Minor errors in providing personal information in the application form at the time of buying policy can lead to hassles later during the time of claim. For instance, applicant name spelled incorrectly, mistake in date of birth, etc.
  • Lethargy in documentation: For insurance claim, if the relevant documents including diagnostic reports and medicine bills are not submitted properly, then you may face problems in recovering the full amount. Even if a single prescription slip is missing from the entire medical file, you will be denied the claim to that extent.

What to do to ensure a smooth claim settlement process?

  • It is important to understand the policy thoroughly before buying one. Be familiar with the terms and conditions of the policy including waiting period, number of diseases and the procedures covered for treatment, cap on room rent, etc. In the case of any doubts, seek information from your insurance agent. Having complete policy information will help to avoid surprises in the future and you will be mentally and financially prepared for it.
  • Ensure to renew the policy on time to avoid its lapsation. Register for mobile alerts with the insurance company or broker for timely reminders. You can also set an alert in your smart phone calendar for policy renewal. Continuity in policy will not just aid in smooth claim settlement but also ensure benefits like no-claim bonus.
  • In the application form, a lot of questions are asked pertaining to age, past and current health condition, ongoing medication, existing health policies, if any, nature of occupation, consumption of alcohol, tobacco, etc. All these factors provide the health insurer the risk he is taking to insure you and he is relying on you for all this information. So, while buying an insurance policy, disclose all the requisite details honestly or else it would result in your loss in the future.
  • Do not rely on agents to fill up your application form. If you get stuck, clear your doubts with the agent but fill the form yourself. Check all the details in the proposal form thoroughly before signing on the dotted line. After receiving the policy document, check all the details carefully again. In the case of any discrepancies, inform your agent or insurer immediately and get it corrected.
  • Timely intimation to the TPA or health insurer is important within 24 hours of hospitalisation. Further, it is your family who will do all the running during the crucial hour of your treatment. So, it is important that they are aware of the location of policy documents, health card, etc., to ensure a hassle free settlement for you.

 Despite taking a health insurance policy and paying premiums, you do not want your claim to be rejected and then run from pillar to post for money. Following the above simple guidelines right during the application of health policy will ensure you and your loved ones do not face any inconvenience in claim settlement.


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