OneInsure Blog
Post By Shweta
What to do when your Health Insurance Claim is Rejected?
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Health Insurance Claim Rejection
Our main aim while buying a Health Insurance Policy is to be covered for any medical contingencies. Sometimes we blindly trust on our agent and buy a plan which may not be helpful at all times. It is important to know the benefits & exclusions before
Let us find out what needs to be done when such situations occur:
- IDENTIFY WHY YOUR CLAIM WAS DENIED:
Before calling the insurance company and accusing them of the health claim rejection, know the reason for the rejection. Ask yourself below questions first before taking any further step:
- Did you claim for any Pre-Existing Diseases? Was there some information which you thought was not important to disclose and did not bother to inform the Insurance Company/ Broker?
- Was there a claim that you registered which was not payable under the policy (Eg. Cosmetic Surgery, Laser treatments, Aesthetic surgery, dental treatment?
- Have you claimed for any Self-Inflicted conditions – i.e. Liver Diseases due to excessive smoking or drinking?
- Have you read the Permanent Exclusions listed on the Policy Wordings? Was the claim part of the permanent exclusions?
- Have you submitted all the documents properly? Have you missed on some information or failed to give some bill which was part of the hospitalization?
- Have you registered the claim during the waiting period?
- Have you checked if the claim amount is over and above the Sum Insured? Has the Sum Insured been exhausted or beyond the Sum Insured?
- Was there any Sub-Limits applicable or was it exceeding the limit?
If the answers to the above questions are “Yes”, then, unfortunately your claim can get rejected. It is always a good practice to understand the policy documents so that you don't face such issues.
Our advice is that you should always read the policy Terms & Conditions Carefully.
- KNOW WHO TO CALL FOR ANSWERS:
Some denials are easier to fix by just asking the right person the reasons for denial.
First Call your Insurance Company. Check with the company the reason why the claim was denied. Do ask the insurance company if there was any billing error or some information is missing.
Always Keep Records of your Past & Present Medical History. Whenever you are discharged from the hospital, whether your claim was Cashless or Reimbursement, do keep a copy of your Medical Bills & Hospital Papers. Keep the name of the person at Insurance/ TPA Desk you talked to along with the date of discussion & what procedure was followed.
In case your Doctor has missed some information or didn’t use the right code, always call your doctor and ask him to fix the error and resend the paperwork to the insurance company.
- UNDERSTAND THE REASON FOR REJECTION:
Once you have understood the matter follow the below steps to get a proper solution
- If your claim was rejected because of incomplete information or papers call the Insurer or TPA to rectify the errors. A record of your past medical history and hospital bills should be kept handy.
- If your claim was rejected due to unfiled documents, first get hold of all the relevant documents from the hospital and then approach the Insurer or TPA for resubmitting the unfilled documents.
- If your claim was rejected due to “Treatment medically not required” as per Insurance Companies findings, then gather the appropriate medical information & doctor prescribed details to prove your case. File a fresh appeal with appropriate papers & medical records to the insurer along with a formal written letter. If you have the Medical Opinion from the Doctor that would be an added advantage.
- TAKE YOUR COMPLAINT FURTHER:
If your still not convinced about the reply received from the insurance company & have already escalated to the complaint desk, then you may approach the Ombudsman to support you further. You may lodge a complaint regards to the claim rejection within 30 days post receiving a response from the insurance company.
Our Opinion:
When you plan to buy a Policy it is important to understand the policy and buy from a Trusted Source. We at OneInsure, provide personalized solutions to all our customers for any insurance needs. Whether you have any corrections to make in your policy or any concerns with your claim, our expert team will assist you in sorting it.
