What do you do if your health insurance claim is rejected?

IRDAI has mandated that no claim that is genuine should be rejected merely on the basis of certain technicalities and that the insurer’s decision of rejecting the claim must be based on sound logic and valid grounds. But, there are still 5 major reasons behind a claim being rejected and before we discuss how to deal with rejection, we should also be aware of their cause:

5 Biggest reasons behind claim rejection:

1. Incorrect information – Many people do not provide correct information to their insurer. They may hide their medical histories, may not have informed the insurer about other policies they have, or they may hide their lifestyles (smoking, alcoholism, etc.) among other things. This information is pertinent as they are important factors in assessing your risk and premium. Providing incorrect information would inevitably lead to a claim being rejected.
2. Insufficient paperwork – Yes, there is a bureaucratic element to insurance and they need all the relevant papers for processing the request. This may include diagnosis, prescriptions, bills, and many other documents that you’ll need to keep handy and organised to avoid rejection.
3. Procedure not required – Certain procedures that you may have undergone may not have been medically necessary or covered under your policy. An insurer can reject your claim, or a part thereof, based on this fact.
4. Exclusions – There are a number of exclusions mentioned in a policy that are not covered. They could be anything from pre-existing conditions (during the waiting period) to clauses like self-harm, that would lead to your claim being rejected.
5. Delay – Insurance policies have certain timelines regarding submission of documents that one should adhere to. A delay could also lead to your claim being rejected but those can be challenged on valid grounds.

But there are still a few things, as follows, you can do after your claim is rejected:

1. Get in touch with your insurer – The most important and obvious thing to do is to get in touch with your insurer and figure out the exact reason behind the rejection. You can also speak with insurance counsellors who may assist with your case. A lot of trivialities can get resolved at this stage and your case may get a reconsideration. Remember that multiple appeals can be filed.
2. Organise and resubmit documents – Go through your policy again, collect all the relevant documents, medical papers, original hospital bills, the doctors’ certificates, the discharge summary, etc. and fill the forms properly again. Request help with the forms from your insurer that there may not be an error at your end.
3. Prove your case – If your claim is rejected on medical grounds try getting professional opinion from medical practitioners and relevant medical authorities regarding the necessity of said procedure. This is necessary to prove that your claim was valid and the policy should be honoured.
4. Insurance Ombudsman – Insurance ombudsman is the highest authority of appeal, prior to courts, where you can file an appeal. The authority works like a consumer forum and is meant to safeguard your rights as a policyholder. If your insurer does not respond favourably or rejects your claims on invalid reasons, you can write to the ombudsman and file your case there.
5. Go legal – This is often the last resort, and usually very expensive, where you take the insurance company to court and fight a legal battle for your claims. Usually, matters do not come to this point but if you feel that you have a genuine claim that your insurer is not honouring then it is within your rights to sue them in the court of law.

Photo by Tim Gouw on Unsplash.

OneAssure is a distribution platform that helps you make right decisions on matters where health and finances converge. Visit oneassure.in to know more about your health insurance choices.