Health insurance is a safety net that helps manage the high cost of medical treatment. However, getting your claim rejected after paying premiums for years can be a frustrating experience.
Understanding the reasons behind claim rejection and how to avoid them can help you make the most of your policy when it is needed the most. Read on to learn more about the measures you can take to ensure your health insurance claim is settled promptly and smoothly.
What Is Health Insurance?
Health insurance is a financial agreement between you and an insurance provider that covers medical and surgical expenses incurred due to illness or injury. It may reimburse expenses or provide direct cashless treatment at network hospitals.
Today, with tools like a health insurance calculator, you can estimate your premium and choose a plan that suits your budget and coverage requirements. However, choosing the right policy is only the beginning; ensuring smooth claim processing is equally important.
Understanding these reasons in advance can help you take preventive action.
Tips to Avoid Health Insurance Claim Rejection
Here are the key steps to prevent health insurance claim rejection and ensure your medical expenses are reimbursed without hassle.
1. Disclose All Pre-Existing Medical Conditions
When buying health insurance, you must declare all your existing health conditions such as diabetes, hypertension, or asthma. Hiding or misrepresenting any information may lead to claim rejection later.
Insurance providers assess risk based on disclosed health conditions. If you fail to inform them, they have the right to reject the claim under non-disclosure.
2. Understand the Policy Terms and Conditions Thoroughly
Many policyholders do not read the fine print. You must understand what is covered, what is excluded, and the waiting periods for specific illnesses.
For instance, most health insurance plans have a waiting period of 2 to 4 years for pre-existing conditions. Claims made during this period for those conditions may be denied.
3. Ensure Timely Renewal of Policy
Claims cannot be made on a lapsed policy. Ensure you renew your health insurance before the due date to maintain continuity and avoid loss of benefits like no-claim bonuses.
A lapsed policy not only leads to claim rejection but may also require you to undergo fresh medical screening when reinstating it.
4. Notify the Insurer Immediately During Hospitalisation
In case of planned hospitalisation, inform the insurer or the third-party administrator (TPA) at least 48 to 72 hours in advance. For emergency hospitalisations, do so within 24 hours.
Delayed notification may lead to delays in approval or outright rejection of your cashless claim request.
5. File the Claim Within the Stipulated Timeframe
Health insurance claims need to be filed within the specified period mentioned in your policy, usually within 15 to 30 days of discharge. Missing this timeline can lead to automatic claim denial. Ensure you keep track of all documents and submit them within the allowed time.
6. Keep All Relevant Documents Ready
Whether it is a reimbursement or cashless claim, having the correct documentation is essential. This includes hospital bills, discharge summary, diagnostic reports, prescriptions, and claim forms.
Incomplete or illegible paperwork is one of the most common reasons for rejection. Ensure you submit all documents in the correct format.
7. Use Network Hospitals Whenever Possible
Cashless claims are easier to process at network hospitals. These hospitals have a tie-up with the insurer, which ensures faster pre-authorisation and settlement.
If you get admitted to a non-network hospital, the insurer will only accept a reimbursement claim, which is subject to stricter scrutiny.
8. Avoid Claims for Excluded Treatments
All health insurance policies have certain exclusions like cosmetic procedures, dental treatments (unless resulting from an accident), or experimental treatments.
Filing a claim for these excluded treatments will always result in rejection. Review your policy documents to understand what is not covered.
Avoiding claim rejection in health insurance is mostly about staying informed and proactive. Always disclose accurate information, understand your policy terms, renew your plan on time, and keep documentation ready. By doing so, you increase your chances of having a smooth claim settlement experience when the need arises.