Why Health Insurance Claims Get Rejected ?

You buy a health insurance policy to protect yourself from unforeseen contingencies. It protects your savings accumulated over many years of hard work.

But what if your claim gets rejected?

Things such as late renewals or missing documents can trouble you at the time of applying for a claim and, consequently, substantial medical debt. Some of the common mistakes to avoid:

Pre-existing illnesses

  • Pre-existing illnesses are not covered from day one.
  • The regulator has prescribed the maximum waiting period of four years for pre-existing illnesses.
  • After four years, insurers are bound to cover all pre-existing illnesses.
  • Companies may offer policies that have shorter waiting period.
  • Diseases such as hypertension and cataract are covered after two years.
  • All diseases arising out of earlier complications, such as obesity and hypertension, may be considered as pre-existing illnesses.
  • To avoid last-minute hassles it is always good to disclose all health-related problems at the time of buying the policy.

Not covered in health plan

  • It is always good to know what a policy excludes if it is difficult to understand what it includes.
  • Since every policy comes with a set of exclusions, read them carefully.
  • Some illnesses are covered only after a certain number of years.
  • Understand who all are included in your family floater policy and group policy.
  • In case of a critical illness plan check out the number of diseases covered.
  • You should know in critical illness plans, the insured has to survive for at least 30 days after the diagnosis.
  • A critical illness policy doesn’t cover pre-existing diseases and no claim can be made during the first 60-90 days of the policy.

Gap in renewal

  • Always renew your policy before the due date.
  • A new policy is assigned if you do not renew the policy on time.
  • Claims filed during the gap period are rejected.
  • Moreover, you are denied the no-claim bonus for not renewing the policy on time.
  • For every no-claim year, you get a bonus of 5 per cent up to a maximum of 50 per cent.
  • Apart from no-claim bonus it affects your waiting period.
  • Waiting period starts afresh if your policy lapses, unless you port the policy.

Policy wordings

  • Legal language of the contract can be complicated.
  • Take time out and sit with your agent to understand what it means.
  • Be aware of sub-limits under different heads such as room and consultancy fees.
  • Make sure the patient is in hospital for at least 24 hours before making a claim.

Incorrect information

  • Fill correct information while buying a policy.
  • Any revelation about health at a later stage could lead to claim rejection.
  • Even at the time of applying for a claim incorrect information could lead to rejection of the claim.
  • Spell the name of the patient and doctor correctly, otherwise it leads to unnecessary hassles.
  • Give correct set of papers, such as hospital bills, when applying for a claim.
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