Health insurance claim rejections: Things to be done

Ashish MehrotraMax Bupa Health InsuranceAll industries face certain mandatory questions and for health insurance one of the biggest poser from the customers is, “would I get the money at the time of claim submission?” This question in fact is the most prevalent concern encountered by both insurers and customers in this industry, which so far has managed to touch only about 5 % of the population. While there are several reasons for rejection of a claim, we first need to understand one basic fact that no insurer wants to hold back the money or a genuine claim. But yes, the claim has to be genuine and should abide by the basic set of conditions which customers agree to while signing the insurance documents. What statistics sayA survey conducted by Max Bupa revealed that 40% policy holders are unaware about the claim process. While only 25% read about claims process actively, 60% rely on agents to understand its process.ChallengeThe key challenge with claim pay out in health insurance is that customers do not read their policy documents at the time of purchase and thus are unclear about the stated policy exclusions and waiting periods till the point of claim. It is imperative that customers invest time in understanding their health insurance cover and share their health conditions with the insurer to the best of their knowledge at the time of policy purchase.For smooth settlement of their claims, the customers must ensure that:1.They are aware of what their policy covers and what is not coveredIt is imperative that customers invest time in understanding their health insurance cover and share their health conditions with the insurer to the best of their knowledge at the time of policy purchase. Reading and understanding what the policy covers is of utmost importance.2.The necessary documentation is complete at the time of filing for claimSee the health insurance claim form that you sent to the insurance company to check whether all the information is accurate- the important two things to check are- name and policy number. Along with the medical insurance claim form, check the other documents provided for accuracy and correct data to avoid any rejection.3.They are aware of waiting periods in the policy (in case of pre-existing ailments)One should be aware that Pre-existing illnesses are not covered from day one. It is always good to know what a policy excludes. Since every policy comes with a set of exclusions, read them carefully. The regulator has prescribed the maximum waiting period of four years for pre-existing illnesses. Some companies offer to cover pre-existing diseases after two years. It is always good to disclose all health-related problems at the time of buying the policy.4.The claim is filed with the insurer at the earliestWhile it is important that you file your claim at the earliest, it is important to know how to submit a claim to your insurance company. The business of insurance is based on trust and requires people to disclose all the relavant information regarding their family, lifestyle, profession and any health problems related to them or their family members. Customers should disclose every major or minor medical condition as many times non-disclosures are unintentional due to lack of awareness. Medical history and occupation of the seeker is carefully scrutinised by health insurers as they look at the long-term costs of financing health care. While some people are simply unaware of importance of disclosure, others hide it to seek the facility provided by a health insurer. However, it is advised that people should know that companies are very careful about the rules and regulations as mentioned in the policy. The relationship between an insurer and a person wanting to undertake an insurance contract is made in good faith, and the person wanting to be insured, must disclose all relevant matters associated with the policy. There is however an effective way of approaching this - if policy holders are adequately aware of the intricacies of their policy. There are times when policy holders face claim denials or rejection. While the rejection might seem irrational and illegitimate, but a closer look might show valid cause for dismissal. The anxiety and burden of having a legitimate insurance claim delayed can make an already difficult situation much more stressful and may lead to devastating consequences. Hence, talking to your insurer to understand the plan as well as the terms and conditions at the time of policy purchase is critical. It is hence crucial to file the claims appropriately as per the policy documents. The time taken to settle a claim is an important factor for people seeking medical insurance policy, but claims settlement is a layered process. The more informed you are as a healthcare consumer, the better the system will work for you. It’s important to understand why your insurer would want to delay a particular treatment. Consequently, an assurance on quick turnaround time may not necessarily translate into real time payment of bills. It is advisable that the customer notifies the insurer about the claim at the earliest. Customers also need to be prudent, know more, and take informed decisions. As the saying goes, knowledge is power!