11 Reasons Why Your Cashless Health Claims Can Get Denied

Why Your Cashless Health Insurance Claim Could Get Denied?

With cashless health insurance claim, policyholders are relieved from the burden of paying hospital bills out of pocket. In fact, previously policyholders could avail cashless treatment only at network hospitals of the insurer but with an update released in 2024, you can now avail cashless treatment across all hospitals irrespective of whether it is a part of insurer's network or not.

Still there are multiple instances when health insurance companies in India can deny your cashless claim. Take a look at some of the key reasons below:

1. If Treatment is Taken at a Blacklisted Hospital

   Your insurance company will deny your cashless claim request if you have been admitted to a hospital that is blacklisted from the list of the insurer . This is because there are some hospitals that insurance provider do not cover due to multiple reasons that might involve charging high fees, failing to meet Insurance Regulatory and Development Authority of India (IRDAI) standards, overbilling for cashless claims, involved in corrupt practices, etc.

2. If the Submitted Documents are Incorrect or Incomplete

   In case of cashless claim settlement, the hospital is required to send a pre-authorization request to your insurer seeking permission for your cashless treatment. Along with the pre-authorization form, they are required to send the medical documents of the insured, including test reports, doctor's prescriptions, etc. In case the documents sent to the insurer or TPA are incorrect or any of the documents are missing, then your cashless claim request will get denied.

   People also read: List of Documents Required for Health Insurance

3. If Your Disease is Not Covered Under Your Health Policy

   Your health insurance company is liable to pay for your medical bills only for the diseases or medical conditions that are covered under your mediclaim policy. In case you are receiving treatment for a disease that is not covered by your insurer, then the company will reject your cashless claim request.

4. If Your Illness is PED and Your Waiting Period is Not Over

   Most health insurance plans cover pre-existing diseases after a waiting period of 2 or 3 years. In case you are admitted to a hospital for the treatment of a pre-existing disease, then your insurer will reject your cashless claim request if the PED waiting period is not over.

   People also read: Pre-existing Disease (PED) Cover from Day One

5. If Your Pre-Authorization Request Was Delayed

   When you are admitted to a hospital in case of medical emergency, the hospital is supposed to send a pre-authorization form to your insurance provider within a stipulated time period. In case the hospital fails to do so, then the insurance company has the right to reject your cashless claim request.

6. If Your Registered Contact Details Do Not Work or are Incomplete

   In order to settle your health insurance claim request, the insurance company requires your contact details as well as your bank details. In case your contact details registered with the insurer are incorrect or not incomplete, then they might be unable to settle the claim and can deny your cashless claim request.

7. If Medical History is Not Disclosed

   When applying for health insurance, it is important to provide accurate and complete information about your medical history. If you fail to disclose any pre-existing conditions or past treatments, the insurance company may deny your cashless claim request.

8. If the Sum Insured is Exhausted

   Every health insurance policy has a limit on the amount it will cover, which is commonly known as the sum insured. So, if the total expenses exceed this limit, the insurer will not cover the extra costs, and you will be required to pay out of pocket. Therefore, it is important to keep track of your medical expenses to avoid exhausting your coverage.

9. If Hospitalisation Was Not Necessary

   Health insurers typically cover the costs of hospitalisation when it is deemed medically necessary. If your hospital stay is considered unnecessary or if it could have been managed through outpatient care, the insurer may deny your cashless claim request.

10. If the Medical Issue is Not Justified

    Health insurance companies can deny cashless claims if they believe the medical condition or treatment is not justified. This can happen if the treatment or hospitalisation does not align with standard medical practices or is considered unnecessary by the insurer.

11. If the Reason for Hospitalisation is Different

    If the reason for your hospitalisation turns out to be different from what was initially claimed, your insurer may deny the claim. For example, if you stated that your injury was caused by a simple fall, but it was later found that it occurred while engaging in a risky activity like horse riding or an extreme sport, the insurer may refuse to cover the costs.

What to Do If Your Cashless Health Insurance Claims Get Rejected?

In case your health insurance company has rejected your cashless claim request, then you can address the issue in the following ways:

1. Understand the Reason for Rejection

   When your claim is rejected, the insurance company will provide a reason for rejection. Understand the reason carefully to know why the claim was denied. Common reasons could be incomplete documents, exclusions in the policy, or treatment not being covered.

2. Contact the Insurance Company

   You can call your insurance provider or visit their customer service centre to clarify the reason for rejection. You can even ask for guidance on how to resolve the issue. Make sure you keep your policy number and claim ID handy for faster assistance.

3. Review Your Policy Details

   Go through your policy document to check if the treatment or condition you claimed for is covered. Often, rejections happen due to misunderstandings about policy terms. Therefore, look for clauses related to coverage, exclusions, and waiting periods to understand the situation better.

4. Gather Missing Documents

   If your cashless claim request is rejected due to incomplete or incorrect documentation, collect the required documents. This could include additional medical reports, doctor's prescriptions, hospital bills, or identification proof. Once you have all the necessary documents, submit a formal request for claim reconsideration.

5. Escalate the Matter if Needed

   If your claim is denied after reconsideration, you can escalate it to the grievance cell or approach the Insurance Ombudsman. They are authorized to handle disputes between insurers and policyholders.

   People also read: How to File a Reimbursement Claim Under Health Insurance?

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