Why your health insurance claim could be rejected?
23 July 2020
We have all heard stories from others about how their health insurance claim got rejected at the last moment. While that’s always a possibility, if you know your health insurance plan well, fill the form right with all the details and understand the circumstances under which a claim can get rejected, you can avoid a similar fate. So, here are 7 most common reasons for claims rejection.
Incomplete or incorrect form
This is probably one of the most common causes for a health insurance claim rejection. While buying your policy, make sure your form is filled correctly as details such as incorrect names or even missing information can lead to a rejection.
Diseases or conditions that you’ve had since before purchasing a health insurance plan are called pre-existing conditions. Whether you get coverage for treatments related to these conditions or not is at the insurer’s discretion. You are required to disclose all pre-existing conditions in your insurance form truthfully.
Violation of terms and conditions
It can’t be stressed enough that you must be familiar with your health insurance policy thoroughly. Reading the policy wordings of your plan is the best way to understand exactly what coverage you are receiving. Make sure your claim is within the scope of your policy and does not violate any terms and conditions mentioned in your policy.
Health insurance plans often tend to vary with respect to the coverage they offer. In other words, each plan can have different exclusions, i.e. things that are not covered. For instance, your mediclaim plan might cover hospitalisation expenses but may exclude the cost of the ambulance. So, if your claim is based on an exclusion, it might get rejected. Make sure you understand what all benefits you are being provided.
Most health insurance plans come with a waiting period before which you cannot make a claim. How long this period is depends on your plan and the type of claim. For example, a general claim can have a waiting period of a month which means you cannot make a claim for hospitalisation within a month of buying health insurance. However, ailments such as Cancer could have a waiting period of up to 4 years, during which time you cannot make a claim for the same disease. The duration is pre-defined in the policy document. The claim which includes a medical condition covered under the waiting period is liable to be rejected.
Failure to renew policy
A health insurance policy needs to be renewed in order to avail financial protection against medical conditions. A claim filed against a lapsed or expired policy would invariably result in rejection.
It is also critical to make an honest disclosure of your or your family’s medical condition with details of any pre-existing diseases or any family history of diseases at the time of buying the health insurance policy. If you fail to disclose any such condition at the time of purchasing the insurance, your insurance and claims can be rejected later.
Another thing to keep in mind is to ensure you have adequate documentation to support your claim. Apart from the above listed reasons, your claim can be rejected by the insurance provider for on other counts too. But if you are a little careful and proactive while purchasing your insurance and making a claim, things will move smoothly. So, read your policy documents carefully, and know why you are purchasing a health insurance plan.