How to Avoid Rejection of Health Insurance Claims

Health insurance provides financial support to policyholders by covering medical bills, hospital bills, consultation fees, and ambulance costs, to name a few. It brings mental peace and security to the insured.

However, there are times when a health claim is dismissed and this often leads to confusion and bitterness. There are a few basic reasons why the application could be rejected, and it is essential to know them in order to avoid mistakes that could lead to the rejection of the application.

Policy Duration

Most health insurance plans are fixed-term contracts that require annual renewal to keep the policy operational. Sometimes policyholders don’t realize their policy has expired and only find out when their claims are rejected, which comes as a big shock to many. Please note that if the policy has expired, the insurance company is not liable to pay the claim.

To avoid such unpleasant experiences, it is crucial to follow policy renewals closely to ensure that one is covered from start to finish. In case you missed the policy renewal, don’t panic, most insurers offer a 15-day grace period, during which you can renew the policy without losing the benefits acquired during the term of the policy. However, any claim occurring during the break-in period will not be covered by the insurer.

Non-disclosure of pre-existing medical condition or other material information

It is important to disclose any pre-existing conditions or conditions that the insured suffers from, such as blood pressure, cardiovascular conditions, hypertension, etc. If a person has ever had major surgery, they should disclose that as well. It is also important to disclose any new medical conditions or conditions that one may have acquired during the year, when renewing the insurance. In a health insurance policy, it is of utmost importance to share health related details with the insurer to avoid hassles at the time of claim. Some pre-existing conditions have permanent exclusions or may materially impact the decision to accept the proposal, so it is important to disclose these details.

Waiting time

Waiting period in health insurance refers to the period of time predefined in the policy during which the claim cannot be presented for the mentioned disease or condition. The waiting period begins with the start of the policy and varies from insurer to insurer and from illness to illness. The policyholder must serve the waiting period before the insurer becomes liable to pay for the condition mentioned. The policyholder should carefully review the waiting period clause of the policy for clarification on the length of the waiting periods against the conditions specified. If a claim is made during the waiting period, it will be rejected.

Coverage of illnesses by the policy

All insurance policies explicitly mention the list of coverages and exclusions, and if the policyholder raises the claim against a disease that is specifically part of the exclusion lists, the claim will be rejected. Therefore, one must go through the list of exclusions when purchasing the policy to find out what is not covered by the policy.

Deadline for filing a claim

Insurance policies mention a stipulated time period within which the policyholder must make the claim, usually the policy allows a period of 60 to 90 days from the date of the discharge to file the claim. Failure to comply with the mentioned deadline may lead to the rejection of the complaint. It makes sense to file the claim soon after the discharge. The insurer may admit the claim for a serious reason for delay in presenting the claim.

Insufficient/incorrect documentation

Sometimes applications, especially refund requests, are rejected due to missing or incorrect documents. The policyholder must submit all original documents, test reports, doctor’s consultation letters and other required documents with the completed claim form to avoid any problems.

To ensure smooth settlement of claims, it is also highly recommended to choose a preferred network hospital for treatment, as you can avail cashless facilities, get better rates, waiver of some fees and benefits of other uninsured items in these hospitals. .

Most insurers have an extensive network of hospitals, spread across the country, and this helps in getting a hassle-free claim settlement. Even if an insured files a claim for reimbursement, he will not encounter any major issues with the settlement of the claim, as long as he has completed the claim form thoroughly and submitted all the required supporting documents.

As long as a claim is admissible under the policy and is valid, the claim will be paid and the policyholder must be assured of it.

(The author is Health Administration Team Leader, Bajaj Allianz General Insurance)

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