Your medical insurance claim may be denied for a few reasons. You might not think much of it. However, those whose claims were rejected would find the process to be very arduous and punishing. But this can be avoided. To ensure that you do everything to make sure your medical insurance can be claimed, it is essential to understand the grounds for denying a claim. It’s also critical to understand preventative procedures. The saying “it is better to be safe than to be sorry” is common usage. Similar to this, it is better to avoid rejection in the insurance industry than take corrective action later.
If you can persuade the insurer that your claim is legitimate, the insurer may consider your claim after it has been rejected. To take corrective action, you must first understand why it was denied. Your claim may be rejected for a variety of reasons. These might result from being admitted to a hospital that is not in your network, from ignoring exclusions, etc. Let’s go over the four grounds for rejecting your claim in more detail.*
- Going above the sum insured limit:
Have you ever heard of the term Sum Insured? No matter which policy you choose, there is always a sum insured. The sum insured is the annual amount you, or in the case of health insurance plans for family, your family, have access to, depending on your chosen plan. If you use up the entire sum for a given year, your subsequent cashless claims could be denied. However, the insurance might reimburse you in the future if some of your sum assured is still intact.*
- Disregarding exclusions of the plan:
The majority of plans may not offer health insurance coverage in India for some conditions. These are clearly listed as “not covered” in the policies. These are sometimes referred to as exclusions and are essentially diseases for which you cannot submit a claim.
If specific policies cover them, there could be a waiting time in place for any such condition. Therefore, if you submit a cashless claim for a prohibited disease or medical condition, it could be denied.*
- Obfuscation and factual misrepresentation:
Some common reasons for rejecting claims are nondisclosures, partial disclosures, and incorrect disclosures of crucial information, such as age, occupation type, income, current insurance plans, serious illnesses, or pre-existing medical conditions. Any mismatch between the declaration and the reality at the time of filing claims could result in denial because coverage is provided based on the information provided by the proposer on the proposal form. The ideal way to solve this issue is to complete out paperwork accurately and promptly.
- Going over the time limit:
You have a set amount of time to submit a reimbursement request under a health insurance coverage. In case of emergency admission, the time limit is 24 hours following the patient’s admission. In other circumstances, it may vary depending on the type of policy you’ve chosen and the sort of treatment you’re receiving. You must submit your application by the deadline to ensure your claim is accepted.*
You should thoroughly understand your health insurance coverage, ideally from the moment of purchase, to prevent cashless claim rejection. The next step is to compare health insurance plans online in order to see what is available and choose the one that suits your needs well. Additionally, it is important to keep track of all your paperwork, including pre-and post-hospitalisation costs, hospitalisation records, diagnostic test results, discharge summaries, and investigation findings. These records may be vital if your insurance requests clarifications.*
*Standard T&C apply
Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.