Health Insurance

How To Appeal Against Rejected Health Insurance Claims?

Nov 28, 2021

How To Appeal Against Rejected Health Insurance Claims?

Health insurance is a very beneficial and handy product to have. In fact, health insurance is no longer a luxury - it is now a necessity. With health problems on the rise and medical inflation also in place, it becomes important for everyone to have a good health insurance cover. Health insurance covers a vast range of health conditions which prove to be advantageous for many people. However, every health insurance plan comes with a list of clauses. Because of this, health insurance claims get rejected from time to time. If you have faced rejection, you always have the option to appeal against it. Read on to know more.

Reason Behind the Health Insurance Claim Rejection

Health insurance claims are often rejected due to a certain or specific reason. As the policyholder who faced rejection, you should try to understand why this happened. The common reasons for health claim rejections include:

  1. Claim made for an exclusion - 
    As mentioned above, every health insurance plan comes with a list of exclusions. For example, injury caused due to substance abuse is an exclusion. If the insured person was hospitalised because he had a road accident after consuming alcohol, he will not be eligible for the mediclaim cover and his health insurance claim will be rightfully rejected.
    Pro Tip: Check the list of exclusions. Some exclusions are common for all plans, all companies like driving under alcohol, etc. But some exclusions could be specific to your health condition. So, check the same well before filing for a claim.

     
  2. Waiting Period:
    There are some ailments under the waiting period, during which claims are not admitted. For example, for a cataract operation, there is a waiting period of 2 years. So, for the first 2 policy years, any claim for cataract operation would not be admitted.
    Pro Tip: Check for the waiting period before planning hospitalisation and treatment so that your claim is not rejected.

     
  3. Claim made on an expired policy - 
    You can only make a claim if the plan is active. If you fail to pay the premium on time and the policy lapses even for one day, you cannot make a health insurance claim. Any claim made on a lapsed policy will be rejected.

    Pro Tip: If your policy is still in the grace period, you can pay your outstanding premium and then file the claim. If not, then your policy needs to go for a revival, if possible. In that case, you need to give a declaration of good health before the policy can be reinstated. So, filing a claim under a lapsed health insurance policy might be quite a difficult task. Hence, remember to pay your premiums on time!

     
  4. Incorrect documentation - Certain documents are needed to be submitted to get a health insurance claim. If there is an error in the documentation process, your claim will be rejected right away.

    Pro Tip: The easiest way to overcome this concern is to opt for cashless hospitalisation, as the hospitals are pro in handling such documentation issues. This becomes a hiccup for claiming on a reimbursement basis.

     
  5. Person not covered under plan - 
    Family floater health plans cover many members of the same family under a single plan. If you make a health insurance claim for a person who is not covered, you will obviously face a health insurance claim rejection.

    Pro Tip: Check the permutations and combinations of family members under which plan before filing a claim to avoid rejection.

     
  6. Non-disclosure at the time of policy inception:
    If there has been an issue of non-disclosure or misrepresentation of material facts, then it might lead to a rejection of the claim. For example, if you have travelled abroad within a period of 90 days prior to opting for a covid specific health insurance plan and the same was not clearly mentioned in the form at the time of opting for the policy, it would surely lead to a rejection of the claim.

    Pro Tip: Ensure you mention all relevant information accurately on the form at the time of opting for the cashless health insurance plan in order to reduce your chances of a claim being repudiated.

     
  7. Pre-existing ailment:
    This is one of the most popular reasons for the rejection of a claim. If there has been an exclusion or a postponement of coverage for any PED(Pre existing disease) specified on your policy document, then all claims pertaining to that during the excluded tenure would surely be rejected. 

    Pro Tip: If you have any PED at the time of opting for a health insurance plan, check your list of exclusions or waiting period before filing the claim.

     
  8. Duration of hospitalisation:
    In order to file a claim, you need to be hospitalised for a minimum tenure of 24 hours for claiming an in-patient hospitalisation. Else the same would be treated as daycare.
    Now, any hospitalisation less than 24 hours does not qualify for insurance coverage. Also, all daycare treatments are not covered.

    Pro Tip: You need to be admitted into the hospital for a minimum of 24 hours for filing an insurance claim.

     
  9. Filing a late claim:
    There is a tenure for filing an insurance claim. There is a procedure for doing the same. Both need to be adhered to for getting the claim accepted. If the tenure is exceeded, i.e. the claim is filed after the maximum number of days after the hospitalisation, or the procedure is not followed, it would surely lead to rejection. For example, there needs to be an intimation provided to the insurer within 24 hours of hospitalisation for most insurers in order to admit a claim. If this is not done, there is a possibility of rejection of the claim.

Things to check after your health insurance claim has been rejected:

  1. Check the letter of rejection of the claim and its possible justifications
  2. Check it with a professional or your policy bond to understand its ramifications
  3. Do your own research to check if there is something you might have missed for which claim was rejected, like original bills, receipts, prescriptions, etc. which could be provided now 
  4. Call the customer service department of the insurance company or the TPA and ask why your claim was rejected.

Assess the reason and see if the claim was rejected due to any of the above-mentioned factors. If that is the case, sadly, you cannot raise the claim again or appeal against the rejection. However, there are ways in which you may refile the claim and appeal for the claim to be admitted.

What to do after your health insurance claim has been rejected?

 

Step 1: Re-appealing 

If you have identified the reason behind the rejection, you can rectify it and file the claim once again. There is no restriction on this. 

For example, if your health insurance claim was rejected because you submitted the wrong documents, you can refile the claim with the correct documents and then your claim will surely be processed successfully.

At the time of re-appealing, you must speak to the principal insurance officer or the underwriter to understand the “REAL” reason for the rejection so that it can be rectified and re-filed.

Step 2: Escalate the matter to higher authorities

If your claim is not getting processed accurately or on time, you can escalate the matter to the higher authorities of the company. Each company has its own Grievance Redressal Cell and the escalation matrix is provided. All you need to do is to follow the grid and then escalate the matter within the company to check if the claim can somehow be admitted!

 

Step 3: Approaching the ombudsman

If however, your claim was rejected even when you were well within the policy limits, your plan was active and the paperwork was done properly, you can approach the insurance ombudsman to get an appeal against the rejection. An ombudsman is a person appointed by the IRDA. He works as a mediator between the insurer and the policyholder. He re-evaluated the insurance cover and the claim and tried to resolve the issues in an out-of-court settlement. 

Step 4: Consumer Forum or the Court of Law:

The only step after the Ombudsman stage is to go to Consumer Forum or the Court of Law.

Steps to ensure the claim is not rejected further

There are some ways to ensure the health insurance claim is not rejected at all:

  1. Be aware of the exclusions - You have to be mindful of all the health insurance exclusions stated in the policy brochure. If you do not know what the exclusions are, you may very well end up making claims for conditions that are not covered. If however, you are well aware of them, you will know what to claim for and what to leave out.
  2. Make sure the policy is active - The next and perhaps the most logical thing to do is ensure your health insurance cover is active, pay your premium on time and keep your policy active as you never know when a claim will have to be made. You will get a grace period if your policy lapses, but claims cannot be made in this grace period. As a result, keep the policy from getting expired and make claims whenever it is needed.
  3. Ensure proper documentation - And last but not the least, you have to ensure that all your papers and documents are in place. Fill the forms properly, get all the bills and memos from the hospital, preserve the doctors’ certificates, etc so that you can file a proper health insurance claim and get it honoured in no time. 

If you follow these tips, there is a lower chance of your health insurance claim being rejected in the first place.

Conclusion 

If you have faced a health insurance claim recently, understand why that happened. Rectify the issue and make the claim again. If that doesn't work, approach the insurance ombudsman. And then, for your future claims, ensure you file them carefully and receive the claim amount without any issues.

Share article with your friends
visa verified mastercard pcidss compliant rupay
  • Paytm Insurance Broking Private Limited. Address: 136, 1st Floor, Devika Tower, Nehru Place, NEW DELHI, South Delhi, Delhi, India, 110019
  • Registration No. 700. Valid till 16/02/2023
  • CIN - U66000DL2019PTC355671