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

reasons for health isurance claim rejection

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?

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Health Insurance Claim Rejection
Reasons Behind Rejection
Steps to Follow if Claim Rejected
Appeal Process for Claim
How to Prevent Claim from Rejection?
Frequently Asked Questions

What is Health Insurance Claim 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.

Reasons Why Your Health Insurance Claim May Get Rejected?

While having health insurance is essential, it is also important to know that it comes with certain terms and conditions. Thus, there are some factors that might lead to health insurance claim rejection, such as the following:

Reason	Description
The Claim Form or Policy Document Has The Wrong Information	If you have provided any incorrect information in the claim form (such as the patient’s name, doctor’s name, or health condition) or if you have not disclosed any information in your policy document (such as any pre-existing medical conditions), your claim might be rejected.
Overlooking the Policy’s Exclusions	All insurance policies have a set of exclusions where particular ailments or treatments are not covered under the policy. These might include injuries related to adventure sports, cosmetic procedures, or alternative treatments. So, if you make a claim for these situations, it will be rejected.
Filing a Claim During the Waiting Period	For some pre-existing conditions or treatments, there is a waiting period, and you cannot make a claim related to such conditions before this waiting period is over.
The Wrong Documents Have Been Submitted	In case you have filed the wrong documents for the claim (including medical reports, hospital bills, discharge summary, and prescriptions) without double-checking them, it can lead to claim rejection.
Exceeding the Time Limit for Filing a Claim	Insurers will give you a certain period of time to file a claim, usually 60 to 90 days from the date of discharge. If you exceed this time limit, your claim can be rejected.
You Have Already Used up the Sum Insured Amount	Generally, your policy will have a certain sum insured amount, and after it has been used up by previous claims made during the year, some insurers will deny new claims.
The Policy Has Expired	If you have forgotten to renew your policy on time, and it has lapsed, any claims you file will be rejected. Even if it is during the grace period for policy renewal, claims might not be accepted.

Steps to Follow if Your Health Insurance Claim is Rejected

what are the steps to follow if claim gets rejected

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.

What is an Appeal Process for Medical Insurance Claim?

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.

How Can You Prevent Your Health Insurance Claim from Being Rejected?

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.

FAQs about Health Insurance Claim Rejection

All

What all documents do you need to submit while making a claim?

The documents you need will depend on the kind of claim you make. For Cashless Claims, you just need to fill in the required form given by the TPA at the hospital. On the other hand, for a Reimbursement Claim, you will need to submit your health invoices, including medical bills, doctor’s prescriptions, etc.

What happens if you file a claim during the waiting period?

If a claim is filed before the completion of the initial waiting period, it will be denied by the insurance company, except in the case of accidental hospitalization.

Will making a claim affect my health insurance premiums?

While the IRDAI’s Health Insurance Regulations 2013 say that your health insurance premium can’t be changed for at least the initial 3 years, post this period, our premium can increase upon renewal. One of the reasons for this increase could be a recent history of claims for surgeries, serious illness, or other medical issues.

Can you make a claim if hospitalization is less than 24-hours?

Yes, you can if it is a daycare procedure or an OPD – provided that you’ve opted for an OPD cover in your health insurance.

What do you do if an insurance claim is rejected?

If your insurance claim is rejected, review the denial letter to understand why. Next, check your policy details and gather all relevant documentation. Contact the insurance company for clarification and file an appeal if necessary.

Why is my health insurance claim rejected?

Common reasons of rejection include:

Missing or incorrect documentation
Pre-existing conditions
Policy exclusions
Claim filing errors
Benefit limits

What should I do if my health insurance claim is rejected?

If your claim is rejected, contact your insurance provider immediately to understand the reason and discuss possible solutions. You may need to provide additional documentation or appeal the decision.

Can I appeal a rejected health insurance claim?

Yes, you can typically appeal a rejected claim. Follow your insurance provider's specific appeal process and submit any required documentation.

How long does it take to appeal a rejected health insurance claim?

The appeal process can vary depending on the complexity of the case and your insurance provider's policies. It may take several weeks or months to reach a decision.

What happens if my health insurance claim appeal is denied?

If your appeal is denied, you may have the option to file a complaint with your state's insurance department or seek legal advice.

Can I file a complaint against my health insurance provider if my claim is rejected?

Yes, you can file a complaint with your state's insurance department if you believe your insurance provider has acted unfairly or in bad faith.

How can I prevent my health insurance claim from being rejected?

To help prevent your claim from being rejected, carefully review your policy and understand its terms and conditions. Then, submit all required documentation on time, completely, and accurately.

Can I file a health insurance claim if I have not paid my premiums?

No, your insurance coverage may be suspended or terminated if you fail to pay your premiums. Make sure to pay your premiums on time to maintain your coverage.

I have term insurance with critical illness rider. My health claim was rejected, can I use the rider instead?

Yes, if your illness is listed under the rider of term insurance policy and meets the conditions (like stage and diagnosis proof), you can claim it separately. It’s a one-time lump sum benefit and doesn’t depend on hospitalisation bills like regular health insurance does. Read the rider's terms carefully before claiming.

My health claim was denied due to pre-existing conditions. Will it affect my life insurance claim later?

Possibly. If you didn’t disclose pre-existing illnesses when buying your life insurance policy, it could lead to rejection of future claims. Always disclose full medical history in all insurance forms, even if it increases premiums, so your loved ones don’t face problems during claim settlement.

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

Table of Contents

What is Health Insurance Claim Rejection?

Reasons Why Your Health Insurance Claim May Get Rejected?

Steps to Follow if Your Health Insurance Claim is Rejected

Step 1: Understand Why Your Claim Was Rejected

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

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

Step 4: File the Claim Again

Step 5: If Needed, Approach the Nearest Ombudsman Office

Step 6: File a Case Before the Consumer Court

What is an Appeal Process for Medical Insurance Claim?

1. Submit an Internal Appeal

2. Send in an External Review

3. Legal Recourse

How Can You Prevent Your Health Insurance Claim from Being Rejected?

FAQs about Health Insurance Claim Rejection

What all documents do you need to submit while making a claim?

What happens if you file a claim during the waiting period?

Will making a claim affect my health insurance premiums?

Can you make a claim if hospitalization is less than 24-hours?

What do you do if an insurance claim is rejected?

Why is my health insurance claim rejected?

What should I do if my health insurance claim is rejected?

Can I appeal a rejected health insurance claim?

How long does it take to appeal a rejected health insurance claim?

What happens if my health insurance claim appeal is denied?

Can I file a complaint against my health insurance provider if my claim is rejected?

How can I prevent my health insurance claim from being rejected?

Can I file a health insurance claim if I have not paid my premiums?

I have term insurance with critical illness rider. My health claim was rejected, can I use the rider instead?

My health claim was denied due to pre-existing conditions. Will it affect my life insurance claim later?

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