Avoiding Health Insurance Claim Rejections: Key Reasons And Solutions

Most health insurance companies have commendable claim payment ratios and are continuously striving to improve. However, there are certain situations where claims are rejected as a last resort. As a policyholder, facing a rejected claim can add significant stress, especially during a hospitalization. This article will delve into the top nine reasons for health insurance claim rejections and provide steps you can take to avoid them.

Common Reasons for Health Insurance Claim Rejections and How to Avoid Them

1. Incorrect Information or Misrepresentation

Providing accurate information is crucial when filling out your health insurance application form. Any intentional or unintentional misrepresentation can lead to claim rejection. Important details include:

• Age
• Income
• Existing medical insurance policies
• Occupation, especially if it’s hazardous
• Hobbies, particularly adventure sports like hiking or scuba diving Ensure you fill out the application form yourself to avoid errors and omissions. Accurate information helps the insurance company decide on the acceptance and premium of your policy.

2. Non-Disclosure of Pre-Existing Conditions and Habits

Failing to disclose pre-existing illnesses, family medical history, or lifestyle habits like smoking and drinking can lead to claim rejection. To avoid this, fully disclose:

• Any pre-existing conditions
• Family medical history
• Smoking habits, including daily cigarette consumption
• Alcohol consumption, including quantity and frequency This information allows the insurer to price the risk appropriately and apply necessary exclusions or waiting periods.

3. Claiming During the Waiting Period

Health insurance policies have specific waiting periods. Claims made during these periods will be rejected. Key waiting periods include:

• 30-day waiting period: Applicable to new policies, except for accidental claims.
• Maternity waiting period: Typically 24-36 months.
• Specified diseases/procedures waiting period: Usually 24 months.
• Pre-existing diseases waiting period: Typically 24-48 months.
• Critical illness waiting period: Generally 90 days from policy inception. Review your policy documents to understand these waiting periods and plan your claims accordingly.

4. Cashless Claims at Non-Network Hospitals

Cashless claims can only be made at network hospitals. If you choose a non-network hospital, your claim will be rejected. Always verify if the hospital is part of the insurer’s network before admission for cashless treatment.

5. Claims for Non-Covered Services

Some services are not covered under standard health insurance policies. These may include:

• Dental treatments
• AYUSH treatments
• Outpatient Department (OPD) services
• Maternity claims* Check your policy to see if these services are covered and under what conditions.

6. Exclusions

Certain treatments and procedures are typically excluded from most health insurance policies, such as:

• Cosmetic or plastic surgery
• Gender change treatments
• Treatments due to participation in hazardous sports
• Treatments arising from criminal activities
• Treatments for alcoholism or drug abuse
• Sterility and fertility-related expenses Review the exclusions section of your policy to understand what is not covered.

7. Claims Under a Lapsed Policy

Health insurance policies must be renewed within a specific period to remain active. If your policy lapses due to non-payment of the renewal premium, any claims made will be rejected. Set up an auto-debit mandate for timely premium payments and keep track of your policy expiry dates.

8. Claim Amount Exceeding the Sum Insured

Each health insurance policy has a maximum sum insured. If your claim amount exceeds this limit, the insurer will only approve up to the available sum insured. Regularly review and update your coverage to keep pace with medical inflation.

9. Late Notification to the Insurance Company

Timely notification of hospitalization to the insurance company is crucial. For planned hospitalizations, seek prior authorization. For emergencies, inform the insurer within 24 to 48 hours of admission, as specified in your policy.

Ensuring Your Claim is Accepted

Understanding and avoiding these common pitfalls can significantly reduce the chances of your health insurance claim being rejected. Key steps include:

• Accurately filling out your health insurance application
• Fully disclosing medical history and lifestyle habits
• Understanding policy terms, waiting periods, and exclusions
• Keeping your policy active through timely renewals
• Promptly notifying the insurer of any hospitalization By following these guidelines, you can ensure a smoother claims process and reduce the likelihood of rejection.