Top 10 Reasons for Health Insurance Claims Rejection

During any medical emergency, the first thing that every policyholder looks for is a hassle-free and timely claim settlement. But, do you know that even if you have the best health insurance policy, there are chances of claims rejection? Health insurance companies work under a tight window. The underwriting of claims based on the terms and conditions laid down by IRADI (Insurance Regulatory and Development Authority of India). So, here you can read the most important reasons for health insurance claims rejection:

Claim for Exclusions

Exclusions are the predefined treatments/medical procedures/diseases/conditions that are not admissible under the policy coverage. If you file the claim for such exclusions, your claim gets rejected. So, read the exclusion list thoroughly.

Inadequate Documents

Health insurance companies required certain documents to approve the claim. It includes the original copies of the claim form, diagnosis, doctor’s prescription, discharge summary, medical and hospital bills, etc. If you submit inadequate documents or miss any of them, there are chances the claim management team may reject your claim.

No Timely Intimation

It is mandatory to inform the customer support team about your hospitalization. Timely intimation within 24 hours in case of emergency and before 48 hours for planned hospitalization is required. If you fail to do so, your claim request will not approve.

Hiding Medical History

Under mediclaim policy for family or individual health insurance,  it is advisable to disclose every insured member’s medical history while buying it. Hiding the medical record or pre-existing diseases of any insured member may result in claim denial due to non-disclosure of information. 

Cashless Hospitalization in Non-Network Hospital:

At times, it happens you admit to the non-network hospital due to urgency. In that case, you can file for reimbursement after paying all your hospital bills from your pocket. But, you cannot ask for a cashless hospitalization claim in a non-network hospital. It is available only at network hospitals. 

Hospitalization is Required:

Until you have the OPD cover, most health insurance companies like Care Health Insurance offer separately. You cannot ask for pre and post-hospitalization expenses reimbursement. For such expenses, hospitalization for 24 hours is mandatory.

Policy Expiration:

You are not entitled to file a claim if your policy is expired. If you want to continue with the coverage, you should make sure that you renew your policy timely.

Switch to New Policy

If you have changed your policy and health insurer, you need to obtain a new preauthorization and verify that its healthcare practitioner accepts the latest insurance. Also, the hospitals are empaneled. The health insurance company will deny any claim submitted using a patient’s canceled insurance policy.

Claim During Waiting Period

Under mediclaim policy for family or an individual policy, the health insurance company will not accept your claim during the waiting period. You have to wait till the completion of the waiting period to file the claim.

Wrong Process

Before filing the claim, acquaint yourself with the right procedure. You should know what channel you need to follow, what sorts of documents are required to file the claim, etc. The wrong process may lead you to disappointment.

Top Health Insurance Companies in India Offer Hassle-Free Claim Settlement

Below are top health insurance companies in India that offer the best health insurance with timely claim settlement:

Health Insurance CompanyClaim Settlement RatioNetwork Hospitals
IFFCO Tokio92.66%4000+
Care Health Insurance92.3%8250+
HDFC Ergo90.32%10000+
Max Bupa Health Insurance83.92%4500+
Star Health78. 15%8800+

So, read about the claim procedure and follow the guidelines to avoid claim denials.

News Reporter