In light of the escalating expenses associated with healthcare, a meticulously crafted health insurance policy can serve as an essential companion, alleviating the strain of financial obligations while safeguarding access to high-quality medical care.
Nevertheless, acquiring such a policy is the initial step towards protecting one’s health. Additionally, you must comprehend and adhere to policy guidelines to prevent your insurer from denying your claim, which could leave you disheartened and frustrated. Acquire knowledge of the list of potential denial reasons for health insurance claims to prevent such occurrences.
Claims for health insurance may be denied for a variety of reasons, including experimental treatment or the submission of documents containing incorrect information. There are several frequent causes for claim denials.
- Delay in notifying the insurer:
In the event of a medical emergency, it is imperative that you promptly notify your insurer. In planned situations, your insurer should ideally be notified before hospitalisation; in exigencies, they should be notified within twenty-four hours of your admission. To obtain this information, please contact the customer service help desk via email or by calling the number provided on your insurance policy. Failure to comply with the designated timeframe could potentially lead to the denial of your claim. The majority of medical facilities provide an insurance help desk that can aid you in notifying your insurer of the medical issue promptly.
- Claims submitted for expenses not covered by the health insurance policy:
An additional factor that could lead to the denial of your claim is submitting claims for expenses that fall outside the scope of your policy. Pregnancy-related matters, dental care, and cosmetic surgery are generally not instances in which health insurance policies provide coverage. Thoroughly review the terms and conditions of your insurance policy to ascertain the scope of medical issues that fall under its coverage as well as the restrictions that preclude you from receiving monetary compensation.
For example, health insurance policies may generally exclude coverage for medical expenses incurred by individuals who developed maladies within the previous 48 months before policy purchase. The category of ‘pre-existing’ conditions may include anything from diabetes and elevated blood pressure to terminal illnesses like cancer. You should purchase a health insurance plan that meets your specific needs if you have a pre-existing condition. This will mitigate the potential for complications that may arise if your claim is denied.
- Submission of claims during the waiting period:
A waiting period is an established duration during which you are not eligible to utilise specific benefits that are provided by your health insurance policy. Your insurer may deny any claims submitted during the waiting period, with limited exceptions for emergency hospitalisation.
Depending on the insurer, the type of health insurance policy held, particular health or medical conditions, and other factors, the waiting period may vary. An example of this is the two- to four-year waiting period for pre-existing conditions, which must pass before you can file claims for medical expenses covered by your policy. Nevertheless, certain policies offer the option to shorten this waiting period for an additional premium.
- Exceeding the sum insured:
The maximum annual payment that an insurer will make towards your medical expenses is referred to as the sum insured. Any additional claims submitted after this maximum is reached within a year will be subject to rejection, and you will be held liable for any additional expenses.
To illustrate this, consider a straightforward example. Consider an annual sum insured of 10 lakh rupees. Suppose, for the sake of illustration, that you have undergone three hospitalisations within a year, incurring medical expenses of ₹5 lakhs, ₹3 lakhs, and ₹4 lakhs, respectively. Your insurer will reimburse ₹10 lakhs for your medical expenses in this scenario; however, you are responsible for the remaining ₹2 lakhs.
Should you perceive your sum insured to be inadequate in safeguarding against prospective medical expenses, there are several strategies to address the matter. A majority of insurers permit an increase in the quantity insured at the time of policy renewal in exchange for a higher premium. Alternatively, you may purchase a top-up plan, which provides an additional level of financial protection if your sum insured has been exceeded.
- Providing inaccurate information:
The submission of inaccurate or erroneous personal information, including that of individuals covered by your health insurance policy, could potentially lead to the denial of your claim. This encompasses details such as age, income, occupation, existing insurance coverage, pre-existing conditions, and so forth. Likewise, your insurer may deny your claim if there are any discrepancies in documentation about hospital bills, prescriptions, medicine invoices, and similar items.
When purchasing health insurance, be as forthright as possible when completing your personal information and initial documentation to avoid any unnecessary complications. Additionally, ensure that your identification documents are valid and accurate.
- Specific circumstances in which a health insurance claim may be denied include:
Aside from the aforementioned common circumstances, niche situations may also result in the denial of health insurance claims. This scenario may occur if you provide inaccurate details regarding your medical history. While it is not mandatory to disclose every medical visit during the health insurance application process, it is crucial to provide details about recent treatments and surgical procedures.
Additionally, bear in mind that assertions about dubious or experimental remedies may encounter denials unless explicit provisions are outlined in your insurance policy. Claim denials may also occur when the insurer disagrees with the treatment plan or diagnosis that the policyholder has proposed.
When confronted with a medical emergency, a claim settlement that is devoid of complications should be your primary concern. Henceforth, please review the following strategies to reduce the likelihood of medical insurance claim denial:
- Consult the Exclusions List
Constantly adhere to the exclusion list. It includes every situation and case that the claim policy does not cover under RDA regulations. Expenses associated with dental care, weight loss, infertility, or the transmission of maladies are not admissible towards the claim. Therefore, ensure that you have reviewed every exclusion to prevent rejection of your Mediclaim.
- Provide the necessary bills.
This is yet another frequent circumstance in which your claim may be rejected immediately. For prompt claim settlement, you are obligated to provide all medical invoices, including those related to hospitalisation, surgery, medications, and doctor’s prescriptions. Failure to do so will result in the denial of your claim. Therefore, for prompt claim settlement, it is prudent to maintain the original and duplicate copies of all required documents in a single location and submit them within the specified time frame.
- Intimation within Stipulated Time
Notifying the hospital of your condition after the allotted time has passed cancels your claim. Notifying the customer support team of your hospitalisation, including the doctor’s prescription, hospital expenses, and medical bills, promptly or within the designated timeframe is crucial for facilitating a seamless claim settlement. Predictable notification facilitates the claim process, ensuring that there are no complexities.
- Pre-existing disease information should never be concealed.
It is imperative to never conceal any details about a pre-existing medical condition. Providing your insurer with any prior medical history of a pre-existing condition is advisable at all times. Your claim may be denied if your insurer discovers that you have a pre-existing condition during the review process.
- Medical care at Network Hospitals
You are only eligible to receive the benefit if you were admitted to one of the network institutions. Network hospitals are those that have been pre-approved to offer contactless hospitalisation. You may submit a reimbursement claim if you require hospitalisation at a facility that is not in your network. You may begin treatment at one of the network hospitals close to your residence to qualify for coverage.
Health insurance is a highly effective means of safeguarding oneself and one’s family against unforeseen medical expenses. Nevertheless, if any errors occur throughout the claim procedure, you run the danger of having your claim denied. Nevertheless, armed with the aforementioned details, one can file an insurance claim under the proper procedure, thereby diminishing the likelihood of claim denial. If you are currently uninsured, you should investigate the available health insurance policies and select the one that meets your requirements the most.