Claim Rejection / Claim Repudiation
Claim rejection or claim repudiation in health insurance refers to the denial of claim payment by the insurance company to the claimant.
Claim rejection usually happens when the insurer initially screens the information provided in the claim form and finds that the claim cannot be paid. Reasons for rejection include incomplete documentation, delay in providing information, or the condition not covered under the policy.
Claim repudiation usually happens when the insurer fully reviews the claim form provided by the policyholder and after investigation, it comes to the conclusion the insurer has no liability to provide coverage for the claim. Reasons include filing a fraudulent claim with forged documents or non-disclosure of material information.
The difference between claim rejection and claim repudiation in health insurance is subtle. The terms are used interchangeably for a situation when the insurer denies claim settlement. However, claim repudiation usually means a more harsh rejection where the policyholder or claimant might have to face severe consequences. For example, the insurer initiates a legal action against the policyholder for filing a fraudulent claim.
If you want to avoid health insurance claim rejection or repudiation, you must know these steps:
[1] Ensure that you provide the right information during your policy application and claim process.
[2] Disclose all material and health-related in your policy application.
[3] Provide the required documents along with the claim form.
[4] Read your policy terms and conditions to understand your coverage.
[5] Check if your health insurance policy includes any disease-specific sub-limit or waiting period.
[6] Opt for a super top-up plan if your base policy coverage is small to ensure you don’t run out of coverage in critical situations.
In case your genuine health insurance claim is rejected or repudiated by your insurer, here’s what you need to do:
[1] Find out the reason for your claim rejection. It must be mentioned in the rejection letter sent by the insurer. Otherwise, get in touch with your advisor or insurer to get the details.
[2] If the claim is rejected for lack of required documents or information, provide the same to your insurer, asking to re-initiate the claim process.
[3] If your claim is still not accepted, you can reach out to the Insurance Ombudsman and file a complaint. You can also take the legal route and challenge your insurer’s decision in the consumer court.
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