Health insurance is not only important but, essential to secure ourselves and our families. We invest a considerable chunk of our income to get health insurance to make sure that we have financial security during a medical emergency.
Finally, when it comes to claiming health insurance it can be quite frustrating and devastating if the claim gets denied. Most of the time, the policyholder is left clueless in case of claim denial.
If you want to reverse the insurance company’s decision or appeal the claim rejection, it is important to know why your claim can get denied when you can appeal, and what you can do about it.
Reasons for Health Insurance Claim Denied
- Rejection of claim due to non-declaration of any previous medical conditions at the time of purchasing the policy.
- Rejection of claim when the treatment is in the waiting period.
- Rejection when the treatment is not covered by the policy or when the need for hospitalization is not justified (e.g. admission due to headache/fever or for investigation purposes).
Rejection of claim because of documents
- Query documents were not submitted on time
- Documents related to first consultation papers and medical treatments taken for medical history of cases were not submitted
- The doctor’s clarification is missing in the documents
- False reasons were stated
- Mistakes in the medical documentation submitted by the hospital
The first 3 reasons are valid for claim denial but, if your claim has been rejected due to any of the reasons mentioned under the 4th point, then the insured can contest the rejection or denial.
What to Do if Your Health Insurance Claim is Denied?
- Study the reasons carefully and speak to the insurer to get clarity. The insurance company will provide you with all the required information on how you can appeal the rejection notice.
- If you are not clear with the documentation or struggling with the claim, consult a claim expert for assistance. You don’t want to take any chances at this stage and only an expert can guide you through the process.
- Organize your paperwork for the concerns raised by the insurer and represent your case. You need to understand that a human being is handling the claim on the other side and he/she may make mistakes in interpreting the case. So, you must present the facts in an organized manner for seamless claim processing.
- You need to quote all the provisions in the policy that you are using to contest the claim denial. For example, the insurer may deny the claim saying that the treatment is not covered. So, you need to pick appropriate provisions in the policy to contest the denial.
- Make sure you’re neither emotional nor abusive when dealing with the insurer. Be factual and crisp with your statements. Make sure you submit your grievances in a written format – emails or letters. This will ensure that you have all the records and you must also remember to take an acknowledgement letter from the insurer.
- If you’re still not satisfied with the outcome of the claim, consult an expert and file your grievance with the insurer. The insurance company is supposed to revert within 1 month.
- If there is no resolution of your grievance or you are not satisfied with the decision of the insurance company, then you can submit your complaint to the ombudsman or the consumer court.
Conclusion
This entire process can be quite exhausting and frustrating when you are already dealing with a medical condition and making arrangements for the funds. But, you must remain calm while claiming health insurance. Consider all the options you have and don’t give up. Many denials have been recovered with the assistance of an expert claim advisor.
