Eight Reasons Your Health Insurance Claim May Get Rejected and How to Avoid It?

Most health insurance providers that offer the best individual health insurance have an easy claim process. However, there are certain instances where the company may reject the claim as a last resort. No policyholder would like to face this situation, especially during an emergency. The claim getting rejected adds to the stress of a family member getting hospitalized. So, let us try to understand some of the reasons why health insurance claims may get ejected and what you can do to avoid them.

Incorrect Information

When filling out the insurance form, make sure all the information you entered is accurate. There should be no misrepresentation of any information as it may lead to rejection of the claim. This information may be about your income, age, existing medical insurance policies, hobbies, profession, etc. This information helps the insurance provider to decide whether to accept your health insurance application and at what premium. Make sure you look for the best individual health insurance and fill out the form yourself.

Information About Pre-Existing Conditions and Bad Habits

Non-disclosure of information about pre-existing conditions, a sedentary lifestyle, a family history of illnesses, and habits like drinking, smoking, etc., may lead to the rejection of health insurance claims. Some people conceal this information to avoid paying a higher premium and policy rejection. So, when filling out the application form, make sure you disclose the details of any pre-existing illnesses you may be suffering from. 

If some conditions or diseases run in your family, ensure that you mention them in the family history section. In case you smoke, the insurance provider may even ask how many cigarettes you smoke daily. If you have a habit of drinking, you may also be required to disclose the quantity of alcohol you consume and the frequency. 

This information will help the insurance company to price the risk appropriately. If required, they may also include an exclusion or waiting period for coverage of specific pre-existing illnesses.

Making a Claim During the Waiting Period

Every health insurance plan has a certain waiting period. The claim will be rejected if it is made during this waiting period. Some types of waiting periods include 30-day waiting periods, maternity waiting periods, waiting periods for specific conditions, pre-existing diseases, and critical illness waiting periods.

Making a Cashless Claim at a Non-Network Hospital

The claim will be rejected if the cashless claim is made at a hospital that is not part of the network. So, if you want to make a cashless claim, make sure you check with the hospital before admission to see whether the medical facility is in-network with your insurance provider. If it is a non-network hospital, you will have to pay the hospitalization bill from your pocket. You may later submit a reimbursement claim to the health insurance company.

Claims for Services That are not Covered

Certain services and treatments may not be covered under your health insurance plan or may be included in some policies with certain limits. So, if you make a claim for any of these services that are not covered, the insurance provider will reject your claim. Some of these services include dental testament, OPD services, and maternity claims. So, if you want to make a claim for any of the above treatments, make sure you read your policy document and check whether they are covered. Also, check the extent to which they are covered and related terms and conditions. 

Exclusions

All insurance providers consider certain medical treatments and procedures standard exclusions. Some of these include change of gender treatment, cosmetic or plastic surgery, treatment required due to participation in hazardous sports like motor racing, rock climbing, scuba diving, horse racing, etc., and treatment due to a person committing a breach of law with criminal intent, treatment for drug abuse, alcoholism, and other addictive condition, and expenses related to fertility, etc.

Claim Under a Lapsed Policy

Remember that a health insurance policy is valid for a specific duration for which the premium has been paid. So once the duration is over, the policy should be renewed by paying the renewal premium. If you don’t pay the renewal premium within the specified time, the policy will lapse. Making a claim under a lapsed policy will be rejected. So make sure you check the expiry date of your policy and also pay the renewal premium on time to keep your policy active. 

The Claim Amount is Higher Than the Sum Assured

Every health insurance policy has a specified sum insured. The insurance company only approves the claim up to the sum insured left. Since medical inflation is increasing every year, make sure you review your health insurance coverage amount every few years. 

Takeaway 

Apart from this, another common reason for an insurance claim to be rejected is not informing the insurance company on time. So now that you understand why health insurance claims get rejected. Make sure you take the necessary steps to avoid it, especially in medical emergencies. 

Disclaimer: MPB.Health memberships are a non-insurance solution designed to provide access to healthcare services. To determine if this aligns with your specific needs, we recommend consulting a certified expert advisor.