The following are some common reasons why most health
insurance claims get rejected. We have also advised the steps you should take
to avoid rejection.
1) Incorrect information or misrepresentation
While filling out the health insurance application form, you
should ensure that all the information you are filling out is accurate. There
should be no intentional or unintentional misrepresentation of any information;
else, it can lead to claim rejection. The information may be about your:
a. Age,
b. Income,
c. Existing medical insurance policies,
d. Profession (specifically if you are in a hazardous
occupation),
e. Hobbies (specifically if you are into adventure sports
like hiking or scuba diving), etc.
All the above is material information for the health
insurance company to decide whether they should accept the health insurance
application and at what premium.
You should fill out the application form yourself rather
than asking your agent or someone else to fill it out. They may not have all
the required information about you to fill out the form accurately.
2) Information about pre-existing illnesses and bad habits
Non-disclosure of information about own pre-existing
illnesses, family history of illnesses, sedentary lifestyle, habits like smoking,
alcohol drinking, etc., can lead to rejection of health insurance claims. Some
people may conceal this information to avoid paying higher premium and policy
rejection.
While filling out the health insurance application form, you
must disclose the details of any pre-existing illnesses that you may be
suffering from. If some disease runs in your family, you should mention it in
the family history or medical history section.
If you smoke, the insurance company may ask about how many
cigarettes you smoke daily. If you consume alcohol, you may be required to
disclose the quantity of alcohol you consume and the frequency.
All the above information helps the health insurance company
to price the risk appropriately. If required, the insurance company may include
an exclusion or appropriate waiting period for coverage of a specific
pre-existing illness.
3) Making a claim during the waiting period
Every health insurance plan may have certain waiting
periods. If a claim is made during this waiting period, it will be rejected.
Some of these waiting periods include:
a) 30-day waiting period
When a new policy is issued, there is a 30-day waiting
period during which no claim can be made. The exception for this is any claim
arising due to an accident.
b) Maternity waiting period
If the policy provides maternity cover, it is usually
applicable after a waiting period of 24 to 36 months. Also, the cover may be
limited to 2 pregnancies.
c) Waiting period for specified diseases/procedures
The treatment for specified diseases/procedures can be
claimed after a 24-month waiting period from the policy's inception. Some of
these include cataract, varicose veins, piles, sinusitis, etc. The complete
list of these diseases/procedures is specified in the insurance policy document.
d) Waiting period for pre-existing diseases
The claim for treatment for pre-existing diseases can be
availed after a waiting period of 24 to 48 months from the date of commencement
of coverage.
e) Critical illness waiting period
The claim for treatment of any critical illness may be
covered after a waiting period of 90 days from the policy inception date.
Please read the policy wording for details of all the above
waiting periods to understand how and when you can make a claim to avoid
rejection.
4) Making a cashless claim at a non-network hospital
If a cashless claim is made at a hospital that is not a part
of the insurance company's hospital network, it will be rejected. Hence, if you
want to make a cashless claim, check with the hospital before admission if it
is impaneled with the insurance company as a network hospital.
You will have to pay the hospitalisation bill from your
pocket for treatment taken at a non-network hospital. Later, you can submit a
reimbursement claim with the health insurance company.
5) Claims for services not covered
Certain services are not covered under every health
insurance plan. They may be included in some policies with certain limits or
other terms and conditions. If you make a claim for any of these services that
are not covered, the health insurance company will reject the claim. Some of
these services can include:
a. Dental treatment
b. AYUSH treatment
c. Out Patient Department (OPD) services
d. Maternity claim
If you want to make a claim for any of the above, read your
policy document to check whether they are covered. If they are covered, check
the extent to which they are covered and the related terms and conditions.
6) Exclusions
Certain treatments/procedures may be considered standard
exclusions by all insurance companies. It means most plans will not cover them.
Some of these may include:
a. Cosmetic or plastic surgery
b. Change of gender treatment
c. Treatment due to participation in hazardous or adventure
sports, such as rock climbing, motor racing, horse racing, scuba diving,
gliding, etc.
d. Treatment due to a person committing or attempting to
commit a breach of law with criminal intent
e. Treatment for alcoholism, drug abuse, or any other
addictive condition
f. Expenses related to steripty and fertility, etc.
The above of some of the exclusions included in most health
insurance policies. For exclusions specific to your policy, check the policy
wordings (Exclusions Section)
7) A claim under a lapsed policy
A health insurance policy is valid for a specific duration,
i.e., one year or multiple years for which the premium has been paid. Once the
specified duration is over, the policy must be renewed by paying the renewal
premium.
The policy will lapse if you don't pay the renewal premium
within the specified time. If you make a claim under a lapsed policy, the
insurance company will reject the claim. Hence, check the expiry date of your
policy and pay the renewal premium before or on time to keep the policy active.
It is recommended that you set up an auto-debit mandate for your policy to pay
the renewal premium.
8) The claim amount is higher than the sum assured
Every health insurance policy has a specified sum insured.
What if the claim amount is higher than the sum insured left (in case you have
made claims earlier in the same year)? The insurance company will approve the
claim up to the sum insured left, subject to policy terms and conditions.
With medical inflation increasing every year, you should
review your health insurance cover amount every few years. Buy/upgrade to a
higher cover amount to keep pace with medical inflation.
9) Not informing the insurance company on time
If you don’t inform the insurance company about
hospitalisation within the stipulated time, the insurance company can reject
your cashless treatment claim. If it is a planned hospitalisation, you may get
the authorisation prior to hospital admission. If it is an emergency hospitalisation
due to an accident or any other reason, inform the insurance company within 24
to 48 hours of hospitalisation, as per policy terms.
Ensuring that your claim is accepted
We have understood the top reasons why health insurance
claims get denied and what you can do to avoid that. Make sure you fill out the
health insurance form yourself and disclose all information accurately. Once
you get the policy document, read all terms and conditions relating to the
various waiting periods, the network hospitals, exclusions, etc. Pay the
renewal premiums on time. In the event of a hospitalisation, inform the
insurance company within 24 hours. If you follow these suggestions, it is very
likely that your health insurance claim will be accepted.
CONTACT ANIL SALGOTRA : 9906339912
Source : manipalcigna
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