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What to do If Your Health Claim Gets Rejected?

18 May 2022, 3:07 PM

Health insurance is a tool to safeguard oneself financially in times of medical emergency or treatment. Buying a Mediclaim policy is easy but at the time of claim settlement not all raised health insurance claims get settled. Rejection of health insurance claims is stressful as you have been paying premiums regularly for the sole purpose of receiving financial aid in times of medical emergency. So, in the event of claim rejection, remember not to get stressed. This article will help you in understanding the reasons for claim rejection and what to do if your health insurance claim gets rejected.

Why does the Health Claim get Rejected?

One of the most important things at the time of claim rejection is to know why the health insurance claim was rejected. The following are major reasons for your health insurance claim rejection.

  1. Providing Incorrect Information: Providing incorrect information is the biggest reason for the Mediclaim policy claim rejection. Insurance companies work towards safeguarding the lives of policyholders however any lies related to information, the health insurance company will reject your claim out-rightly.
  2. Not Providing Entire Paperwork: The stress may cause the policyholder to provide insufficient paperwork which could result in claim rejection. It is important to provide entire paperwork during the process of claim settlement.
  3. Treatment not Covered: In some cases, the insurance provider will not deem a certain medical procedure fit under health insurance coverage. If the Mediclaim company feels your health insurance claim is unjustified, they will reject your claim.
  4. Lapsed Policy: In case of unpaid premium, the Mediclaim policy gets lapsed and it ceases all the benefits of the policy. A policyholder cannot initiate claim on a lapsed policy and no insurance company shall honour the claim settlement of a lapsed health insurance policy.
  5. Exclusions: Exclusions under a health insurance policy is the list of treatments for which the insurance company shall not entertain the claim. If a policyholder undergoes a treatment that falls under exclusion, the claim shall not be entertained. For example, an attempt to suicide is exclusion and if a policyholder is hospitalized for its treatment, no health insurance claim will be honoured. 
  6. Expired Policy: If the claim is initiated after the Mediclaim policy expires, then the claim is bound to get rejected as all the benefits of the policy cease to exist. 
  7. Unaccredited Treatment: If the policyholder avails treatment from an unaccredited hospital or a non-qualified doctor, then the claim will be rejected.

What to do When the Health Claim Gets Rejected?

In the event of health claim rejection, firstly do not get stressed as you can attempt to reverse the decision of the health insurance company if the claim rejection grounds are any of the following reasons:

  • Delay in submitting all the necessary documents
  • Submitting the query documents late
  • Non-submission of all medical treatment and doctor consultation documents
  • Absence of doctor’s clarification in case history
  • Rejection of claim by the insurer on account of false medical reason
  • The medical documents submitted by the hospital contains mistakes

When a certain claim is rejected for any of the above-stated reasons then here are the steps you can take to undo claim rejection.

  • Submit Proper Documents
    Medical documentation forms the basis of a health insurance claim. In case of claim rejection due to improper documentation then check all your submitted documents again and submit proper documents. In this way, you can reinitiate the claim procedure.
  • Submit Correct Medical Papers
    Submit correct and complete medical papers including original medical bills, doctor’s consultation case history, discharge summary, etc. Submitting correct medical papers will help in the speedy claim process.
  • Submit Appropriate Medical Certificate

In case the claim is rejected on the grounds of unnecessary medical treatment then it is required to obtain sufficient certificates from licensed medical professionals to prove that your claim is correct and indeed the medical treatment was required.

Once you have obtained all the documents that were missing and required, you need to submit them again to your healthcare provider.

  • Approach your healthcare provider with a formal letter reinitiating the claim process
  • Attach required and missing documents with the letter to substantiate the claim
  • Ask for reconsideration of the claim process

Note: Remember, if you do not hear from the healthcare provider within 30 days from the date of re-initiating the claim process, you can approach the higher authority i.e. the Office of Ombudsman.

Thus, here is the entire procedure of what to do if your health claim gets rejected. However, we wish you do not face the situation as it creates a lot of stress in the first place.

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