How to Avoid Health Claim Rejection - Some Tips

Written on Thursday, January 7, 2016
By Bajaj Capital Claim Team

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Sometimes in life, we may face physical as well as financial crisis, both, at a time. In those moments Health Insurance becomes our benefactor. Being covered by a health insurance implies that we cover those unpredictable moments more securely. But, what may happen if the claim is rejected at the last moment, when we require it utmost? It may further increase our problem or end us up head over heels in debt.

In order to avoid such situation, one should take note of the below mentioned reasons of health claim rejections and avoid erring in the future-

A. NON-DISCLOSURE OF FACTS- MEDICAL HISTORY

It has been found that about 60-65 % of the claims get rejected due to non-disclosures, partial-disclosures or wrong-disclosures of significant facts such as age, nature of occupation, existing insurance policies, major ailments or pre-existing medical conditions etc. The information provided by the proposer is of utmost importance. Meagre difference in the information provided may lead to claims rejection. You must know that while filling the form you need to be very careful and instead of getting it filled by someone else, fill the form in your own handwriting. Read the policy wordings very carefully so that you are aware of what is covered and what is not beforehand.

B.  DELAY IN SUBMISSION & INTIMATION

Insurance companies define specific timelines (Standard time of intimation -24 hrs. from date of Admission, Submission-15 days from the date of discharge) within which a policyholder must intimate the insurer in respect of any claims. On the delay of claim intimation or submission of documents to the insurance company, the claims might get rejected.

C. LACK OF KNOWLEDGE

Claim gets rejected for the treatments taking less than 24 hrs. - Except Day care procedure the hospital expenses are covered only if the patient stays for 24 hours in the hospital

Most of the companies do not offer cover for all kinds of non-allopathic treatments, while buying a policy make sure to check the conditions & assist the client accordingly.

If you have taken treatment in a non-registered /less than 15 bed hospital, then there are chances of your claim to be rejected.

The Policy Coverage mentioned in your Health Insurance form must be gone through prudently, as ignorance towards it may lead to claim denial or partial payments in future. Before buying any Health product go through the policy conditions, specifically sub-limits, Co-pay, other caps etc and other details precisely and carefully.

It should also be noted that the Cosmetic Treatment, Eyesight Correction and Mental Disorders are not covered under health policies (unless it’s not specified).

The claim will also be denied in the case where there is a lack of medical necessity. Example: - If any claimant is admitted in the hospital for medical investigation or for any kind of oral treatment, which can be given on OPD basis, the claim will be denied due to the lack of necessity.

Taking admissions before completion of the waiting period under certain ailments (Disease) e.g. Cataract, Hernia etc., The claim in such cases is not provided

Always make sure to think through the above listed points to avoid any sort of hassle at the time of claim. All the genuine claims are settled by the insurance companies, provided the relevant documents as required by the insurance company are duly submitted.

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