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Things to do when your Health Insurance Claim gets Rejected

Ojaswi Indap Ojaswi Indap 27 January 2016

We buy health insurance to be covered against medical contingencies. But a rejected claim can be very depressing. Find out what to do when that happens.

Health Insurance Claim

Alright, so health insurance may not be a hot topic for you. It’s just something at the back of your mind, passively lying in some unused corner. But remember, all is hunky dory till someone gets hurt, and your claim gets rejected.

So between you buying health insurance like a responsible adult and furiously typing enraged reviews on social media about the health insurance company rejecting your claim, we want you to humor us. Sometimes (just sometimes) it’s not entirely the company’s fault when a claim gets rejected.

Okay! Time to put those guns back in the holsters. Before you begin accusing the company start with knowing the reason for claim rejection.

Ask yourself:

  • Was there some pre-existing disease that you forgot to mention before buying the policy? Was it high blood pressure or something that you thought was unimportant to be disclosed?

  • Was it a claim on procedure not falling under curative treatment? – Claims on cosmetic surgeries, dental treatments, etc.

  • Was it a claim on investigative diagnosis? – Hospitalization only for diagnostic purpose and not treatment.

  • Was the claim made for a self-inflicted condition – say liver cirrhosis or lung cancer because of smoking and drinking – or a suicide attempt?

  • Was it a claim for condition listed as permanent exclusion? – Either for pregnancy, congenital or genetic disease, injury during nuclear war, etc.

  • Did you fail to present certain documents – may be a small note you thought to be unimportant – while filing the claim?

  • Did you make the claim intimation after the due date or many weeks after the hospitalization?

  • Was the claim made during the waiting period?

  • Was the claim made after the sum insured had been exhausted or beyond the sum insured value?

  • Was it a claim that was exceeding the applicable sub-limits applicable? May be a packaged treatment that had a sublimit? If the answer for any of the above questions is ‘yes’ then, unfortunately the rejection would be stated as valid and there is nothing more you can do about it. As much as you’d have liked, you cannot blame the insurance company as these little things are also mentioned in the policy clause given to you.

And thus they say, “Read the offer documents carefully!”

What is to be done then?

Well don’t break your head or lose faith in health insurance. In some cases you can still mend for it. But first, understand all the terms and conditions in the health policy and also the reasons for claim rejection. In case you find it difficult to understand a clause, call the insurer and ask for the details. Move ahead only after understanding all the terms well. This will help you to further resolve the claim rejection.

After understand the matter follow any one of the below mentioned steps:

  • If your claim was rejected because of incomplete information then mail the insurer to correct the errors. Do not forget to keep a record of all the correspondence between you and the insurer. You never know you might need them later. In case a TPA was involved inform them.

  • If your claim has been rejected because of unfiled document then ensure that you gather all the documents and approach the insurance company within the number of days specified by them. If TPA is involved then ask the TPA to work on your case once again. Also, resubmit the correctly filed documents.

  • If your claim was rejected because the insurance company finds the treatment medically unnecessary then gather accurate medical data to prove your case. It might be as simple as furnishing medical opinion record or medical research. To process the claim again you would have to file an appeal to the insurer by writing a formal letter and submitting it along with necessary documents and proof. Medical opinion of the doctor in any case would be necessary to add value to your case.

Once you figure out the reason for claim rejection and are ready with documents to support the validity of your health insurance claim, file an appeal. Attach with it all the necessary documents along with the doctor’s opinion. You can appeal multiple number of times until your case is resolved.

If you are still scrolling down then I guess you have followed all the above mentioned steps and still failed, or you are just curious to know more. Well, there is certainly more to it.

In case did follow all the steps mentioned above, and like those never ending quarrels between you and your little sister this fight for claim is not getting resolved, then you can approach Ombusman to support you. You may lodge a written complaint about your claim rejection within the specified number of days, which is often around 30 days post the insurance company’s response.

While choosing a health insurance policy, you have to be cautious. But eventually, at the time of claim settlement make sure that you do not miss out on any document. A few precautionary measures and preemptive strikes may just save you all the trouble and stress of having your claim rejected.

Ojaswi Indap
Written by Ojaswi Indap
From microbial slides to slideshows explaining complex financial products – Ojaswi has come a long way. One of the first to join the content brigade at Coverfox, she has been on a mission to simplify insurance since then.