What to Do if Your Health Insurance Claim is Denied?

Steps to Take if Your Health Insurance Claim Gets Rejected

In the 2024 guidelines, the Insurance Regulatory and Development Authority of India (IRDAI) directed all health insurance companies not to reject claims after a policyholder has paid the premium regularly for 5 continuous years. These 5 years are called the moratorium period in health insurance. Once this period is over, only fraudulent claims or claims related to permanent exclusions can be rejected by the insurer. Thus, if your insurer denies your claim after your moratorium period is over, you can request an explanation from them.

In case the moratorium period of your health insurance policy is not over, you can follow the step-by-step process given below:

Step 1: Find out the reason for the denial of your claim.

Step 2: Once you know why your claim was rejected, make the necessary amends if possible.

Step 3: File the health insurance claim again after confirming with the insurer that the additional information provided is adequate.

Step 4: Send a compelling 'Letter of Appeal' to your insurance company to reconsider your rejected claim. You must mention the reason for buying the mediclaim policy, provide factual details on the recommended treatment plan and provide evidence to support them.

Step 5: You can call the IRDAI's Grievance Cell of Consumer Affairs on their toll-free number or send an email to complaints@irdai.gov.in. You can also use the Integrated Grievance Management System (IGMS) online on the IRDAI's website.

Step 6: Contact the insurance ombudsman for claim assistance if your insurer has rejected your appeal. The ombudsman will verify the facts of the matter and issue fair verdicts.

Step 7: You can also appeal at the consumer courts if you do not find the verdict of the insurance ombudsman favourable.

7 Common Reasons for Health Insurance Claim Rejections

There can be numerous reasons for your medical insurance claim to get rejected. Even a small mistake or ignorance can lead to denial of claims at the time of a medical emergency. Take a look at the various health insurance claim rejection reasons below:

1. Wrong Information

   Most medical insurance claims get rejected if the policyholder has provided incorrect or wrong information while buying the policy. They do not disclose their pre-existing diseases or furnish all the information correctly at the time of purchase to pay a lesser premium. This is one of the biggest blunders you can make and should be avoided to prevent claim denial. Insurers usually find such discrepancies sooner or later and, therefore, reject your claim request for misinformation.

2. Improper Documentation

   A lot of times, health insurance claims are denied due to improper or missing documents. This can happen if you have purchased the policy in a hurry or a non-registered agent has duped you into submitting fewer documents than required. Without proper documents, health insurance companies do not settle claims. In fact, missing documents are one of the major reasons for medical insurance claim rejection In India.

3. Inadequate Sum Insured

   Insurance companies also reject health claims if your sum insured is insufficient/exhausted. This usually happens if you have raised multiple claims in a policy year and your remaining sum insured is not enough to pay for another claim. In this situation, if you file a new claim, your insurer will reject your claim unless you have the restoration of the sum insured benefit.

4. Expired/Lapsed Policy

   Another reason for the rejection of claims is an expired/lapsed policy. If you have not renewed your medical insurance policy on time and it has expired or lapsed, then your health insurance claim will not be entertained by your insurer. This is because your insurer is liable to cover your medical expenses only if your policy is active. If you raise a claim with an expired/lapsed policy, your insurer will reject your claim.

5. Claims Against Exclusions

   If you file a claim for any treatment or illness that is not covered by your insurance company, then your claim will not be accepted. For example, suppose your policy has listed adventure and hazardous sports as exclusions. So, if you raise a claim for injuries resulting from adventure sports, your insurer holds the right to reject it.

6. Claims During the Waiting Period

   If you raise a claim for a disease during the waiting period, your insurance company will reject your claim. All health insurance plans come with an initial waiting period of 30 days. Besides, specific diseases and medical conditions may come with a waiting period. For instance, all maternity insurance policies cover pregnancy expenses after a waiting period of 3 months to 4 years. Thus, if you file a claim for a disease before its waiting period is over, your insurer will reject it.

7. If Your Claim Request is Not Deemed Fit

   Health insurers can also deny claims if they feel you have made an unjustified claim. If they find that hospitalization was not required for your treatment, then your claim request will be rejected and an intimation will be sent to you.

What to Do if Your Insurance Company Denies Your Claim in India?

Once you know the reason why your health insurance claim was rejected, you can take the following actions to amend it and file the claim with the insurer once again:

1. Correct the Data

   Inform your insurer about reinitiating the claim. Gather the data once again and understand where you went wrong. When filling out the claim form again, you can seek help from customer support and make sure that there is no error in the data provided. Doing so will ensure that your claim gets accepted the second time.

2. Proper Documentation

   In case the reason why your claim was not accepted was a missing document, then make sure to provide that document this time. File the claim again with the insurer by submitting all the required documents, including the missing document.

3. Prove that Hospitalization was Recommended

   If your insurance company rejected your claim because hospitalization was not required, then you can submit your doctor's medical prescription suggesting hospitalization. Show the diagnostic reports before hospitalization. If you can convince your insurer or TPA that it was essential to undergo the treatment and stay in a hospital for more than 24 hours. Your claim request must be accepted after you prove the need for hospitalization for your treatment.

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