A common habit is ignoring the small print in health insurance policies. Lack of seriousness and awareness of the implications are to blame for this. Your claim could be denied due to your carelessness with health insurance. Those who don’t fully comprehend the situation’s seriousness might think this seems less harsh. However, those whose claims were rejected would find the process very demanding and punishing.
Therefore, it is essential to understand the grounds for health insurance claim status denial. Nevertheless, it’s also critical to comprehend preventative procedures. In the insurance industry, avoiding rejection is better than taking corrective action later.*
If you can persuade the insurer that your claim is legitimate, the insurer may consider your claim after it has been rejected. To take corrective action, you must first understand why it was denied. Your claim may be rejected for a variety of reasons. These might result from being admitted to a hospital not in your network, ignoring exclusions, etc. Let’s discuss the four grounds for rejecting your claim in more detail.*
- Extending the Sum Insured
Have you ever heard of the term Sum Insured? Whether you choose a family floater or an individual health cover, there is an insured sum whether you choose a health insurance policy or a personal accident policy. The sum insured is the annual amount you or your family have access to, depending on your chosen plan. If you use up all your allowances for a given year, your subsequent cashless claims can be denied. However, the insurance might reimburse you in the future if some of your sum assured is still intact.*
- Disregarding the exceptions
The majority of health insurance plans may not offer coverage for several conditions. These are listed as “not covered” in the policies. These are sometimes referred to as exclusions and are essentially diseases for which you cannot submit a claim. There can be a waiting time in place for any such condition, though, if certain plans or policies cover it. Therefore, if you submit a cashless claim for a prohibited disease or medical condition, it can be denied.*
- Obfuscation and factual misrepresentation
Some common reasons for rejecting claims are nondisclosures, partial disclosures, and incorrect disclosures of crucial information, such as age, occupation type, income, current insurance plans, serious illnesses, or pre-existing medical conditions. Any mismatch between the declaration and the reality at the time of filing claims might easily result in denial because coverage is provided based on the information provided by the proposer on the proposal form. The best way to solve this issue is to complete the paperwork promptly.*
A point to remember:
You have a set amount of time to submit a reimbursement request under health insurance coverage. Regarding emergency admission, the time period is 24 hours following the patient’s admission. In other circumstances, it may vary depending on the type of policy you’ve chosen and the sort of treatment you’re receiving. Your claim may be denied if you don’t submit your application by the deadline.*
You should thoroughly understand your health insurance coverage, ideally from the moment of purchase, to prevent cashless claim rejection. The next step is to compare health insurance plans online in order to see what is available and select the one that suits your needs. Ensure to check the company’s health insurance claim settlement ratio before buying. Additionally, it is important to keep track of all your paperwork, including pre-and post-hospitalisation costs, hospitalisation records, diagnostic test results, discharge summaries, and investigation findings. These records may be absolutely necessary if your insurance requests clarifications.*
* Standard T&C Apply
** Currently, there are 2 tax regimes in India – new and old. To get the tax benefit you desire, choose the correct one after consulting an expert. You can opt for a regime change during the next financial year.
# Visit the official website of IRDAI for further details.
## All savings are provided by the insurer as per the IRDAI-approved insurance plan. Standard T&C apply
Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.