What to Do if Your Health Insurance Claim is Denied in India?

Most people purchase health insurance policies for financial security and peace of mind during medical emergencies. But, after going through a stressful medical procedure or recovering from an illness, the last thing you need is to have your health insurance claim rejected. Unfortunately, this could be possible if there is a mistake in the claims process.

However, can you appeal this decision and ask your insurance company to approve your claim even after rejection?

In the context of health insurance, rejection refers to any refusal of an insurance provider to pay a claim submitted by the holder. There are several reasons this may happen. It is usually an error of submission or due to terms and conditions that may be mentioned in the policy document.

Some common reasons for rejecting claims include errors in the form of personal information or medical facts. In the case of a rejected claim, it would be better to contact your insurance provider to understand why the claim is being denied and what options are available.

Even after a health insurance claim has been rejected, you can ask your health insurance company to reconsider it. To do so, you must convince them that your claim is 100% genuine. First, you need to know it was rejected, and then you can proceed by following these steps:

Step 1: Understand Why Your Claim Was Rejected

The first thing you should do is look for the reason your claim was rejected, as only once you know the reason, can you try to rectify it.

Insurers might reject claims due to issues with the bills or documents, so check for any errors in your submitted claim form, or any mistakes in the documents you submitted. Another reason might be that the insurer might feel that your hospitalization was unwarranted.

However, if the reason was that you had not cleared your waiting period, or your policy had expired, be advised that your claim will not be eligible.

Step 2: Reach Out to Your Insurer, TPA, and Hospital

If you think you have a reason to reapply for the rejected claim, you should contact your insurance company and the third-party representative or TPA to inform them about reinitiating the claim.

You can challenge the claim-related dispute over a call or email. It is recommended that you have a written email to prove your communications. It is also important to contact the hospital and mention the details for enquiry.

Step 3: Gather the Proper Documentation, Data, or Proofs

Based on the reason that your claim was rejected, you might need to correct some information:

• If the reason was missing or incorrect documents, correct this by providing the desired documents with correct details and attestation.
• If there were any errors in your claim form, like your name and the policy number, check the same thoroughly and get them rectified.
• In case your claim was rejected because your insurer felt that the hospitalization or medical procedure was considered unnecessary, you can submit your treating doctor’s letter or prescription suggesting hospitalization as well as any pre-hospitalization diagnostic reports to convince your Insurer or TPA that it was essential to undergo the treatment and stay in a hospital.

You can reach out to a representative of the insurance company, or get the help of your TPA representative to reopen your case and have your claim form and documents corrected.

Step 4: File the Claim Again

Once you have got together all the documents, facts, and any additional information to support your claim, here’s what you must do:

• Write a formal letter to your insurer and TPA, including a statement that includes your reason for the claim being genuine and valid, as well as the correct policy number and claim details.
• Send this letter to your insurer with all the appropriate documents, and a note containing the medical opinion of a licensed medical practitioner to substantiate the claim.

Remember that you can make multiple appeals for claim validation.

If you don’t get a response from your health insurer within 30 days proceed to Step 5.

Step 5: If Needed, Approach the Nearest Ombudsman Office

If you are unhappy with the resolution provided by your insurer you can, approach the nearest Ombudsman office within 30 days of your health insurer’s response.

The Ombudsman will act as a mediator and will arrive at a recommendation concerning your appeal against the insurer’s decision.

Step 6: File a Case Before the Consumer Court

In more extreme cases, if you are also unhappy with the Ombudsman, then as a last resort you may file a case with the consumer court. However, keep in mind that this might require legal aid which might end up costing more than your medical bills, and will also be time-consuming.

There may be instances of claims getting rejected again and again. Here are a few methods to appeal if your claim gets rejected:

1. Submit an Internal Appeal

Request that your insurance provider reconsider their choice. They ought to expedite the procedure if the case is urgent. Ask them to recheck the policy coverage while appealing for medical insurance.

2. Send in an External Review

You can ask an independent review organisation (IRO) for a third-level appeal if the first two appeals are unsuccessful. The insurance company will no longer have the last say to pay your claim in an external review.

3. Legal Recourse

To pursue further action, take legal assistance. File a case against the insurance company with proof of proper documentation and your insurance papers. The legal assistance will help settle disputes.

As the saying goes, “prevention is better than cure”. And so it is important to know what preventive measures you can take to ensure that your health insurance claims are not rejected.

• Don’t have any delays in paying your health insurance premium to ensure continuous coverage.
• Remember to go through the policy document carefully and note the terms and conditions, the exclusions, deductibles and co-payments.
• Ensure that all your details, like your name, address, etc. are the same on all the documents.
• Collect all the required documents and necessary proofs like medical bills, doctor’s prescriptions, at the time of hospitalization.
• Make sure you submit the claim request within the time limit, usually 30-90 days from the date of hospitalization.
• Send all the medical records and documents to the third-party administrator (TPA), and in the case of post-hospitalization costs, this should be done within 90 days of hospitalization.
• Always make copies of all the documents submitted with the claim form to the TPA, for future reference.
• Double-check the insurance claim form before submitting it to ensure that it has all the correct information. You can even keep multiple forms handy in case you make a mistake and need to re-fill it.

If you file a health insurance claim and it gets rejected, it can be a very stressful time. Hence, it is good to know that there are methods that you can use your claim is rejected. However, it is always better to try and avoid rejection than to take these remedial measures after the fact.

Try to make sure not to give your insurer a reason to reject your claim, and always renew your health insurance policy on time so that it is active, and you can file a claim during any medical emergency.