The world of health insurance is essentially to provide people safety nets or finance against unexpected hospital spends. Although they are in many ways a safe route, yet denial of their health insurance claims process can create a lot of bother in life, thereby becoming a serious fiscal burden to all those in line. In this blog, we will discuss the most common reasons for health insurance claims being rejected in India and guide you on how to avoid these pitfalls.
Common Reasons for Health Insurance Claim Denials:
Pre-existing Conditions:
Waiting Period: Most policies have a waiting period before covering pre-existing conditions. Claims arising from conditions existing before the policy’s inception or within the waiting period are often denied.
Non-Disclosure: Failure to disclose pre-existing conditions at the time of buying a policy is the main reason for claims rejection.
Policy Exclusions:
Specific Conditions: Cosmetic surgeries, dental treatments except in cases of accidental injuries, and specific pre-existing diseases are not covered under some policies.
War and Terrorism: Claims related to war, nuclear accidents, or acts of terrorism are usually not entertained.
Self-inflicted Injuries: Claims based on self-injury or suicide attempts are not accepted in most cases.
Incorrect or Incomplete Documentation:
Missing Paperwork: Filing wrong or incomplete paper, such as medical bills, prescriptions, or discharge summaries, can lead to rejection of claims.
Submission after the Due Time: Submission after the given time can lead to rejection of claims.
Violations of Terms Under Policy:
Fraud: Giving wrong information while purchasing policy can lead to cancellation of due policy and the claim submitted will be rejected.
Non-payment of Premiums: If the premium is not paid in time, the insurance policy can be withdrawn and the claim submitted will be rejected.
Incorrect Admission:
Short Hospital Stay: Claims submitted for less stay in hospitals without medical need would be rejected.
Non-Medically Necessary: The treatment not found to be necessary by the medical team of the insurers would be rejected from the claim.


What to Do if Your Claim is Denied?
If your health insurance claim is rejected, as a policyholder, you are entitled to the following:
Right to Know the Reason: The insurance company must clearly and concisely state the reason for rejecting the claim in writing.
Study the Denial Letter: Carefully study the reason for denying the claim from the insurance company.
Collect Relevant Documents: Get all the relevant documents to prove your claim.
Appeal Decision: If you feel that denial is not warranted, then file an appeal with the insurance company within the timeframe given.
Seek External Aid: In case your appeal gets rejected, then you can transfer the issue to IRDAI or you may seek help from lawyers.
Right to be Treated Equally: The whole process of the claim has to be conducted with respect and fairly.
How Not to Have Claim Denials?
Read Your Policy Document Carefully: Understand all the terms and conditions of your policy document thoroughly. This includes what is excluded from the coverage, waiting periods and coverage limits.
Disclose All Your Medical History Transparently: Don’t hesitate to disclose your medical history to avert complications in the near future.
Maintain Proper Documentation: Maintain all medical records, bills, and prescriptions.
Submit Claims Within the Prescribed Time Span: File claims as quickly as possible.
Select a Right Policy: Select a health insurance policy that suits your needs and your background medical history.
Conclusion
Health insurance is a safety net, but it is always important to be aware of the pitfalls that may lead to claim denials. Understanding policy terms, exclusions, and ensuring that all required documents are submitted increases the chances of a successful claim. Always disclose accurate information, stay informed about the waiting periods, and choose network hospitals to make the most of your health insurance.
At VSRK Capital, we are dedicated to providing transparency and clarity with health insurance. If you have questions about your policy or require help in the process of making a claim, please do not hesitate to reach out to our team of experts who can make the process smoother for you.
FAQs
What are the most common reasons for health insurance claim denials?
The most common reasons for health insurance claim denials include non-disclosure of pre-existing conditions, failure to meet policy exclusions, missing or incomplete documentation, treatment within waiting periods, non-payment of premiums, and seeking treatment at non-network hospitals. Understanding your policy terms and conditions can help prevent these issues.
Can incorrect information in the claim form lead to denial?
Yes, there is denial upon the submission of a claim with incorrect information; this is in breach of the utmost good faith required by an insurer.
Does missing a premium payment affect claims approval?
Yes, missing one premium payment would lead to lapse in policy due to which claims made in that period get denied since they are no longer covered.
Do external regulatory authorities exist to handle unresolved disputes with claims?
Yes, the IRDAI of India, together with the Insurance Mediator, settles any unsettled insurance claim disputes in India.