Why Health Insurance Claims Gets Rejected?
Common Reasons for Health Insurance Claim Rejections
Health insurance is a safety net that guarantees financial support during medical emergencies. However, insurance companies can reject your claim if you do not provide an accurate expense bill, have an expired policy, or omit critical medical history.
Find the major reasons explained below.
1.Lapsed or Expired Policy
Repeatedly missing health policy premium payment dates can cause your plan to lapse, removing all the coverage benefits. Additionally, if you fail to renew your health insurance within the grace period, it results in policy expiration, which automatically leads to claim rejection.
2.Claims Made During the Waiting Period
A waiting period is the duration you must wait before filing a claim. It varies depending on the insurer, policy, and specific medical scenarios. Typically, claims filed within a month of purchasing a health policy can lead to rejection.
Additionally, Pre-Existing Diseases (PEDs) require a waiting period of 12/36/48 months based on the condition and the policy terms.
3.Incorrect Information
Insurance claims get rejected if the information on the claim form conflicts with the original information on file. While filling out a claim form, misinformation regarding date of birth, name, previous illnesses, or phone number can lead to a rejection.
4.Delay in Notifying a Claim
Insurance companies have a specific period within which you must file a claim. Otherwise, it will be considered void. A planned hospitalization requires a claim intimation 48 hours before admission, whereas an emergency hospitalization is to be filed within 24 hours.
5.Omitting Information on Pre-existing Diseases
Diseases like diabetes or hypertension must be declared while purchasing insurance. A claim on such pre-existing diseases and other medical discrepancies will be rejected unless proclaimed in the original document.
6.Lack of Supporting Documents
The policyholder must provide the necessary information for the insurance claim. Documents like hospitalization bills, discharge certificates, and test reports are mandatory while filing a claim. If you fail to produce these documents, your claim will be rejected by the insurer.
7.Permanent Exclusions
Check the procedures and treatments excluded in your policy as such claims will be immediately rejected. Cosmetic procedures, self-inflicted injuries, and experimental treatments are among some procedures excluded from standard health insurance policies.
8.Exhaustion of Sum Insured
Your claim may be rejected if you have exhausted the sum insured in a prior medical crisis. As policies are renewed annually, frequent hospitalizations can exhaust the sum insured for the year. In such a scenario, the insurance company has a right to completely or partially reject your claim.
9.False Diagnosis
If a disease is falsely diagnosed and the medical record has discrepancies, the insurance company can rightfully reject a claim filed for it.
10.Prior Assessment
Some treatments need pre-authorization by a Third Party Administrator (TPA) or the policyholder’s health insurance company. If you fail to file for a pre-authorization request with the insurance provider, your claim for the medical procedure may be halted or rejected.
Health insurance rejections are troublesome and can often lead to burdening debts for life. Being aware of the terms and conditions of your policy, keeping up with premiums, and adhering to waiting periods can help you rightfully claim insurance coverage.
Leading medical insurance providers like Star Health enable you to easily keep track of premium payment dates via their app or official website. Also, you can initiate a claim request by calling their 24/7 customer service helpline or sending a ‘Hi’ on their WhatsApp number.
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