Having health insurance gives you financial security in medical emergencies. But what if your claim gets rejected when you need it the most? A denied health insurance claim can be frustrating, stressful, and financially draining. To help you avoid this issue, we’ll look at common reasons for health insurance claim rejections. We’ll also discuss proactive steps to ensure your claims get approved easily.
Top Reasons Why Health Insurance Claims Are Rejected (And How to Avoid It)
1) Providing Incorrect Information or Misrepresentation
A common reason health insurance claims get denied is incorrect or misleading info on the application form. This includes false or inaccurate details about:
- Age
- Income
- Pre-existing health conditions
- Lifestyle habits (smoking, drinking, etc.)
- Occupation and risky hobbies (e.g., adventure sports)
How to avoid it: Always provide accurate and truthful information while filling out the application. Any discrepancy found later can lead to claim rejection. It’s best to personally fill out the form instead of relying on an agent or third party.
2) Hiding Pre-Existing Medical Conditions & Bad Habits
Some policyholders hide health issues or habits, like smoking or drinking, to pay less for insurance. However, insurers thoroughly evaluate medical histories and habits before approving claims.
How to avoid it: Be transparent about your health history, lifestyle habits, and family medical history. Hiding information might help in getting a lower premium initially, but it can lead to a complete claim denial later.
3) Making a Claim During the Waiting Period
Most health insurance plans have waiting periods for certain conditions and treatments. If you claim for a treatment that falls within the waiting period, it will be rejected.
Types of waiting periods:
- Initial waiting period: Typically 30 days from policy purchase (except for accidental cases)
- Pre-existing disease waiting period: Usually 2 to 4 years
- Specific disease/procedure waiting period: 1 to 2 years (e.g., cataract, hernia, varicose veins)
- Maternity cover waiting period: 2 to 4 years
- Critical illness waiting period: Around 90 days
How to avoid it: Understand the waiting period clauses in your policy document. If you have pre-existing conditions, choose a plan with a shorter waiting period or opt for a plan with a waiver for waiting periods.
4) Getting Treated at a Non-Network Hospital for Cashless Claims
Health insurers have tie-ups with specific hospitals where you can avail of cashless treatments. If you seek treatment at a non-network hospital, your cashless claim request will be denied.
How to avoid it: Before hospitalization, check with your insurer to ensure the hospital is part of their network. If the hospital is not listed, be prepared to pay upfront and later file for reimbursement.
5) Claiming for Treatments or Services Not Covered
Not all medical expenses are covered under every health insurance policy. Some exclusions include:
- Dental procedures
- Cosmetic or plastic surgery
- Fertility treatments (IVF, surrogacy, etc.)
- Alternative treatments (unless explicitly covered)
- OPD (Outpatient Department) services
- Weight loss or obesity treatments
How to avoid it: Read your policy document carefully to know what is covered and what is excluded. If you need coverage for a specific treatment, choose a plan that includes it.
6) Exclusions Mentioned in the Policy
Every health insurance plan has a list of exclusions, meaning treatments or conditions not covered under the policy. Standard exclusions include:
- Self-inflicted injuries
- Treatment for alcohol or drug abuse
- Injuries due to participation in hazardous activities (skydiving, motor racing, etc.)
- War-related injuries
- Breach of law-related medical expenses
How to avoid it: Always read the policy’s exclusions section to understand what’s not covered. If needed, opt for additional riders to cover specific conditions.
7) Claiming Under a Lapsed Policy
If you fail to renew your policy on time, it lapses, and any claim made under a lapsed policy will be denied.
How to avoid it: Always renew your policy before the due date. Set reminders or opt for auto-renewal to ensure continuous coverage.
8) Claim Amount Exceeding Sum Insured
Every policy has a predefined sum insured (coverage limit). If your hospital bill exceeds this amount, the insurer will not pay beyond the policy’s coverage limit.
How to avoid it: Choose a health insurance plan with a sufficient sum insured to cover your medical expenses. You can also buy a top-up or super top-up policy to increase coverage.
9) Delayed Intimation to the Insurance Provider
Insurance companies have specific time limits for reporting hospitalizations. If you fail to inform the insurer within the stipulated period, your claim may be rejected.
How to avoid it: Inform your insurance company about planned hospitalizations well in advance. For emergency hospitalizations, notify them within 24–48 hours.
How to Ensure Your Health Insurance Claim Gets Approved
To avoid facing claim rejection, here are some practical steps:
- Fill out the application correctly: Provide accurate and truthful information.
- Know your policy terms: Read your policy document. This helps you understand what is included, what is not, and any waiting periods.
- Keep your medical records ready. Document your medical history, prescriptions, and bills.
- Inform the insurer on time: Always notify your insurer about hospitalization as per policy guidelines.
- Renew your policy on time: Avoid policy lapses by making timely renewal payments.
- Opt for a comprehensive policy: Choose a policy that best fits your health and lifestyle needs.
To lower the risk of claim rejection, follow these steps. This will help make your claim process smoother during medical emergencies.
Conclusion
Understanding why health insurance claims are denied can ease policyholders’ stress during emergencies. By being informed, proactive, and careful about policy details, you can ensure your claims are processed smoothly. Choose a full policy. Share all medical details honestly. Follow the claim process carefully. This way, you can have smooth coverage when you need it most.
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FAQs (Frequently Asked Questions)
What should I do if my health insurance claim is rejected?
If your claim is denied, look into why it was rejected. Then, check your policy document. Finally, appeal the decision with the needed supporting documents.
Can I file a claim if my policy has lapsed?
No, a lapsed policy does not offer coverage. You must renew your policy before its expiry date to avoid losing benefits.
How can I find out if my hospital is in my insurer’s network?
Check your insurer’s website or call customer support to verify the network hospitals before admission.
What happens if my total medical bill exceeds my sum insured?
The insurer will only cover the expenses up to the sum insured limit. Any additional expenses must be paid out of pocket.
Can I still get insurance if I have a pre-existing condition?
Yes, but there may be a waiting period before coverage begins for that specific condition. Choose a plan with a shorter waiting period or additional riders if needed.
