What if My Health Insurance Claim is Rejected?

Health insurance claim rejection is stressful. Unfortunately, we find many people facing this situation. 

In this article, we will try to understand the most common reasons for health insurance claim rejection. We will also look at what you can do if your health insurance claim is rejected.

If your health insurance claim is rejected, we will stand by your side and represent your case. If you purchase your health insurance policy through us, we are always here to help you. 

 

Book a call with us to discuss your health insurance needs with our expert advisors.

 

Our advisor will help you find the right health insurance plan for you and your family. If you wish to buy the policy, the advisor will guide you through your health insurance purchase journey as well.

Reasons for Health Insurance Claim Rejection

Non-Disclosure of Existing Health Conditions: Many health insurance claims are rejected due to non-disclosure of important health information. This could include an existing condition or a health issue from 10 years ago that you may have forgotten about. It does not matter whether you hide such material facts knowingly or unknowingly. 

Your insurer has the right to know all health-related information that is pertinent to making underwriting decisions. Your insurer may reject your claim if you do not disclose any such information. 

Be sure you disclose necessary health-related information while purchasing your health insurance policy. Even if you do not have the details, such as prescription or diagnostic reports of an illness you had 10 years back, make sure you disclose whatever you remember. This might make it difficult to obtain a policy initially but will strengthen your case when making a claim. 

Claims During Waiting Periods: Health insurance policies impose waiting periods on pre-existing conditions and on certain slow-growing illnesses. Other waiting periods may apply depending on your policy’s features, such as for maternity benefits. 

Cover on these conditions becomes active only after you serve the waiting period under your health insurance policy. If you file a claim during the waiting period, your health insurer will reject the claim. Ensure that you know and understand all the waiting periods your health policy imposes. 

Claims towards Exclusions in Health Insurance: If you file a claim for a condition or item excluded from the policy, most obviously, your insurer will reject it. This may include any treatment specifically excluded, such as plastic surgery or gender transition procedures. Or it could be incidental like involvement in criminal activity or a war-like situation. It could even include conditions related to alcoholism or substance abuse that required hospitalisation for treatment.  Here’s a detailed video on “Exclusions in Health Insurance”

Blacklisted Hospitals: Health insurers may blacklist certain hospitals or healthcare providers due to their prior experience of fraudulent or inflated claims. You can get the list of such hospitals from your health insurance company’s website. 

Avoid seeking treatment at a blacklisted or excluded hospital if you want your insurer to pay your medical bill. 

What to Do When Your Health Insurance Claim is Rejected

If you find yourself in such a situation:

1. Insurer: The first step is to reach out to your insurance company and demand a detailed explanation of the reason for claim rejection. Your insurer has to give you the reason for rejection of your health insurance claim in writing.
2. Grievance Cell: If the explanation does not satisfy you, you can write to the grievance cell of your health insurer. The grievance cell of an insurance company operates independently and can relook at and even reverse the decisions made by the claims settlement team. If the grievance cell believes that the claims team has not acted fairly, it can reverse the decision and settle your claim in your favour. You can find the contact details of the grievance cell of your health insurer here. Simply email the grievance cell, providing your policy number and the details of your complaint. You should hear back from them within 30 days of filing your complaint. Unfortunately, this step is mandatory and you can’t skip it even if you understand that the grievance cell is after all operated by the same insurer who rejected your claim and hence it is less likely to reverse the decision made by the claims team.
3. Insurance Ombudsman: If you are still not happy with the response of the grievance cell or you do not hear back from them even after 30 days of filing your grievance, you can escalate the matter to the insurance ombudsman. You can file your complaint online by visiting the insurance ombudsman website or you can file an offline complaint by writing an email, via post or by physically visiting the ombudsman office. Different Ombudsmen serve different territories, so ensure you contact the appropriate Insurance Ombudsman for your region. The Ombudsman acts as a mediator between you and your insurance company, providing a fair recommendation based on the facts of the case.
4. Civil/Consumer Court: Alternatively, you can file a case against your insurer in consumer court. If you are not satisfied. Take your case all the way to the Supreme Court. However, the time and effort involved can make the process challenging for most people. We recommend first reaching out to the Ombudsman to resolve your claim rejection. If you purchase your health insurance policy through us, we will assist you in taking your complaint to the Ombudsman, if necessary. We will file the complaint on your behalf and represent your case.

Summary

1. Health insurance claim rejection is stressful. So it’s better to minimize the risk of claim rejection. To do this, you need to understand the reason for claim rejection.
2. One major reason for health insurance claim rejection is non-disclosure of existing health conditions, whether knowingly or unknowingly. Other reasons include claims filed during the waiting period, claims towards exclusions and treatment taken in a blacklisted hospital.
3. If your health insurance company rejects your claim. You can simply write to the grievance cell, mentioning your policy number and other details, and ask for a resolution. If the response is unsatisfactory, or they do not reply within 30 days, contact the Insurance Ombudsman.
4. Different Ombudsman serve different territories. Make sure you reach out to the appropriate Ombudsman for your area. You can file a complaint on the insurance ombudsman website. Or you can send an email or a post, or you can visit the ombudsman office physically to file a complaint.
5. If you bought your health insurance policy through us and you face claim rejection in future, we will always assist you. We will file a complaint on your behalf and represent your case.