Six Big Reasons for Rejecting a Health Insurance Claim

By | March 22, 2022
At present medical treatment is very expensive. Therefore, it is imperative for every family to have health insurance. Often people avoid taking out a policy saying that health insurance claims are not approved. However, a health insurance policy must be taken after getting sufficient information about the claim.
In this column we have talked about both cashless claim and reimbursement claim in health insurance. Today we will talk about the main reasons behind rejection of health insurance claim.

Failure to disclose facts or conceal information

Whether it is life insurance or health insurance, everyone should fill in all the information in the form honestly while taking the policy. Any injury or injury in childhood, any congenital defect or illness or hereditary problem should be reported to the health insurance company. If not reported in advance and found out at the time of claim, the claim may be denied. People take out health insurance to treat future illnesses, but keep in mind that many companies do not cover the cost of treating illnesses that already exist. Information about any old illness or problem should not be hidden in this.

Lack of documentation

It is important to preserve the letters written by the doctor while undergoing treatment. All the letters before admission to the hospital along with the report of the medicine bill and tests as well as the bill, report, etc. related to the treatment of the related pain done in the hospital have to be submitted to the insurance company at the time of claiming. If there are any shortcomings, the claim may be denied.

Diseases not covered

Health insurance companies do not cover the treatment of many ailments or pains in addition to chronic illnesses under the policy. The details are clearly stated in the terms and conditions of the policy. These problems include dental problems, injuries while intoxicated or injuries during adventure sports, etc. Decide on a policy only after a thorough study of the diseases not covered.

Lack of timely reporting of claims

Sometimes an accident or other incident is so big that the whole focus of the family is on getting treatment. I don’t remember reporting to the insurance company at that time. In fact, the condition is as serious as not having health insurance. If a close relative cannot be notified, the hospitalization should be reported to the insurance company by telling a relative. Some companies have a rule of reporting within 3 hours of hospitalization and some within 3 hours. In these circumstances it is easy to choose a company that needs to be notified at any time of the day or night. The point here is to give the nominee the right to report the hospitalization to the insurance company on your behalf. Such an arrangement is useful in case the policyholder cannot inform himself.

Claim during the policy lapse period or during the grace period

Sometimes people are late in renewing the policy. Insurance companies offer a grace period, but if a claim is made during that period, it may be denied. The reason is that legally the policy lapses on the last day. If the claim is received even on the second day after the policy lapses, it is rejected. From this it can be said that renewal should be done a few days before the last day of the policy.

Waiting period

Health insurance companies cover certain illnesses only after a certain waiting period under the policy. Thus, even the illnesses covered under the policy do not get a claim if they occur during the waiting period. Problems such as cataracts, kidney stones, knee transplant surgery, are covered after a waiting period of two to four years. This period is different in each policy so check what is the rule of your policy.
Q: I have had thyroid for the last ten years. I did not report it to the company when I took out health insurance two years ago. Will any thyroid treatment be covered?
Answer: Most health insurance companies deny the claim if the information is withheld.
Q: My mom is 6 years old. He has to have a knee transplant. If I take a policy today and claim after three months, will my claim be approved?
Answer: Many companies do not cover knee transplant surgery as a chronic disease. In some companies, a claim is granted after a waiting period of three to four years. Your claim will be decided according to the terms of your policy.
Q: My mom suddenly had to be hospitalized and we could not notify the company / TPA for the claim. Can a claim be granted as reimbursement?
Answer: Yes. Reimbursement may be considered for your claim. For that you will have to state the reason for the delay in reporting to the company along with the evidence.

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