Reasons For Health Claim Rejections And Ways To Avoid It

Major reasons for health claim rejections usually comprise the following.

Reasons For Health Claim Rejections And Ways To Avoid It
Reasons For Health Claim Rejections And Ways To Avoid It
Nirmala Konjengbam - 12 June 2019

There are possibilities that a health insurance claim might get rejected for reasons, which usually the insured is unaware of. And this may have effect on the financial health of an individual as one is dependent on the cover taken. It’s important to know all possible reasons that may lead to rejection of health insurance claim.

Commenting on the rejection of health claims, Sukhesh P. Bhave, Head, Accident and Health Claims, SBI General Insurance said, “In order to avoid rejection of health insurance claims, it is always advisable to read and understand the policy terms and conditions carefully. In case if there are some points, which require clarification, get it cleared with the insurance company or the agent. Fill up the proposal form, submit genuine documents at the time of buying a policy in an order and make sure to submit all relevant documents without hiding any facts”.

However, you must understand that, not all entitlements are payable under health insurance claims. Understanding the policy wordings will help to minimise misunderstanding between the insurer and the insured at the time of claim. This way policyholder can decide what to claim rather than unknowingly being stuck with a huge bill. Almost all health insurance companies usually offer a list of hospitals to provide cashless treatment.

“It is also suggested that when treatment is provided at the hospital as a patient you have a right to ask for the requirement of specific test or line of treatment. Sometimes there is a possibility that hospital may perform tests or procedures, which may not be required and the patient also does not question thinking everything would be covered. However, if these procedures are not in line with the medical history of the patient and is necessarily required during their medication, there are many chances that the claim might be rejected”, added Bhave.

Major reasons for health claim rejections usually comprise the following:

Not understanding of pre-existing diseases: Usually individual or family floater policies do not cover pre-existing diseases in the initial period, which may vary from three to four years depending on the plan taken. It is mandatory and advisable that one declares a pre-existing health condition or illness at the time of purchasing a plan.

Read every terms and conditions carefully: One must make sure to read and understand the policy terms and conditions as it may be complex sometimes for a common man to understand. The applicant must read the details to understand exclusions, coverage sub-limits and various terms.

Misrepresentation or non-disclosure of material facts: Insurance principle of utmost good faith very clearly outlines that the proposal is being accepted considering that the proposer has mentioned all his required details truthfully and correctly in the proposal form. Noṇ-disclosure of any detail could lead to issues in future.

Non-Renewal of policy: If policy is not renewed on timely manner, if claims falls during the period when policy expired, then insurance company has the right to reject a claim.

Associated waiting periods: This is usually the time before, which there is no coverage extended for a disease, if there is a claim for a particular disease for, which waiting period is applicable and the claims submitted is for the illness before the waiting period elapses the coverage would not be offered for the same.

Exclusions in the policy: One must thoroughly go through the exclusions mentioned in the policy as it would give a clarity about the uncovered conditions.

At the same time, industry experts also highly recommend to get a most comprehensive insurance plan, which gives a wide coverage. There might be an impression that the cost is bit high however when a claim is lodged this decision of getting comprehensive plan provides a huge support.


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