8 Reasons why your health insurance claim could get rejected

Claims made against your health insurance cover may get rejected for some very basic reasons. Know them to avoid them.

8 Reasons why your health insurance claim could get rejected

The benefits of health insurance become only too obvious during an emergency. The rising cost of medical expenses these days makes it a must-have. However, there are some common reasons why health insurance claims often fail. Let’s look at what these are.

1. Incorrect process

The insurer has a standard claim procedure that you need to follow. It may include informing the insured about the hospitalisation, selecting a recognised hospital, filling the claim form completely and correctly, providing all the supporting bills and reports etc. Failing to do any of these can lead to delay or rejection of your claim. 

2. Pre-existing diseases

Health insurance providers have specific policies about pre-existing diseases. If your health plan doesn’t include pre-existing diseases, claiming insurance against hospitalisation related to any such disease will not be entertained.

Related: 8 health insurance jargons explained

3. Policy period

The health insurance policy remains valid for a specific period. Claiming for treatment outside the validity period is almost certain to be rejected by the insurer. Therefore, timely renewal of health insurance policy is mandatory.

4. Waiting period

Insurance companies specify in their policies about the waiting period in case of certain medical emergencies. If you get hospitalised for such a disease within that waiting period and apply for a claim, the insurer has the right to reject it. 

5. Exclusions

Although a health plan covers health ailments, there are certain medical conditions that are excluded by insurers. This includes cosmetic surgeries, smoking-induced lung diseases, liver problem caused by alcohol consumption. Your claim is likely to be rejected if you claim against one of these conditions. 

Related: Travel insurance exclusions in India

6. Suppression of facts

While your claim is being processed, the insurance firm will study your documents thoroughly. If they find any discrepancies, they will make a note of the same. For example, not disclosing a family history of disease to the insurer but mentioning the same in the hospitalisation form.

7. Claim delay

Putting in a claim after the end of the period specified by the insurer in the policy document can lead to rejection of the claim. This is unlikely in case of cashless hospitalisation, as all claim formalities need to be completed before the release of the patient from the hospital.

8. Excess claim

There is a sum insured in every health insurance policy that is the maximum limit you can claim against the insurance cover. There are family floaters and individual covers in health plans with a predefined limit that can be claimed in a year. In case your medical expenses exceed the sum insured, you will not be able to claim the amount by which it exceeds the sum insured.

Related: How to claim health insurance 

On your part, you should make a complete disclosure at the time of purchasing the policy to avoid any inconvenience later. Besides, it is always important to renew a health plan before it lapses and adhere to the due process when it comes to claiming against the insurance cover. Check these 8 health insurance jargons that you need to know. 


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