Why health insurance claims get rejected and how to avoid it

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Buying health cover bring you peace of mind, but this peace of mind can vanish in case your claim is rejected at the hospital counter. As much as the insurers must pay out valid claims, errors and misconceptions usually cause rejection. Understanding the frequent reasons can save you the shock when you most need your cover.

Non-disclosure of health information

Among the highest reasons why claims fail is non-disclosure at the purchase of the policy. If you conceal pre-existing ailments such as diabetes or high blood pressure to save on premium, the insurers can deny claims in the future. Always be upfront from the beginning.

Waiting period restrictions

Each cover has waiting periods set for certain illnesses as well as pre-existing conditions. Any claim made before the waiting time expiration will be disallowed. Knowing the dates and planning the treatments through that schedule is necessary.

Policy exclusions

Health insurance doesn’t cover everything. Cosmetic surgeries, dental work, or injuries due to risky activities are usually excluded. Many claims get rejected simply because the treatment falls outside the scope of the policy. Reading the fine print before relying on your cover is key.

Lapsed policies

If your premium is not paid, your policy becomes dormant. A claim made during this phase will be ignored regardless of the years you paid earlier. Getting reminders or opting for auto-debit prevent your coverage from unknowingly expiring.

Inadequate documentation

Unsent bills to the hospital, incorrectly identified patient details, or partially completed claim forms can result in delays or outright refusals. Being efficient with your paperwork and verifying facts before submission simplifies the process.

FAQs

Q1. Is reapplication possible if the claim is rejected?

Yes. You can complain with supporting documents or explanation. Where rejection is unjust, you can complain to the insurance ombudsman.

Q2. Are cashless claims more likely to be accepted compared to reimbursement claims?

Not necessarily. They are both governed by the same rules. Cashless just implies the insurer pays the hospital direct.

Q3. How can I prevent the risk of rejection?

Disclose sincerely, be clear about waiting periods and exclusions, pay premiums timely, and be prepared with documents.