Health insurance provides financial support to policyholders by covering medical expenses, hospitalization cost, consultation cost, and ambulance charges, to name a few. It provides peace of mind and security to the insured.
However, there are times when a health claim is rejected, often leading to confusion and bitterness. There are some basic reasons why your claim may be denied, and knowing them is essential to avoid mistakes that can lead to your claim being denied.
Policy tenure
Most health insurance plans are fixed-term contracts that require an annual renewal to keep the policy in place. Policyholders sometimes don’t realize their contract has expired and find out only when their claims are denied, and this comes as a big surprise to many. Please note that if the policy has expired, the insurance company is not responsible for paying the claim.
To avoid such unpleasant experiences, it is crucial that one closely monitor policy renewals to ensure that one is covered from start to finish. In case the renewal of the policy has been lost, you should not panic, most insurers offer a grace period of 15 days, during which you can renew the policy without losing the benefits acquired during the validity of the policy. policy. However, any claim that occurs during the break-in period will not be covered by the insurer.
Non-disclosure of pre-existing conditions or other important information
It is important to disclose any ailment or pre-existing condition that the insured has, such as blood pressure, cardiovascular conditions, hypertension, etc. If one has had major surgery before, they must also disclose this. It is also important to report any new medical conditions or ailments you have acquired during the year, at the time of insurance renewal. In a health insurance policy, it is of the utmost importance to share health-related details with the insurer to avoid inconvenience during the time of claim. Certain pre-existing conditions have permanent exclusions or may materially affect the decision to accept the proposal and therefore it is important to disclose these details.
Waiting period
The waiting period in health insurance refers to the period of time predefined in the policy during which the claim for the aforementioned ailment or condition cannot be filed. The waiting period begins with the start of the policy and varies from insurer to insurer and from ailment to ailment. The policyholder must comply with the grace period before the insurer becomes responsible for paying for the aforementioned ailment. The policyholder should carefully review the policy’s waiting period clause for clarity on the length of waiting periods against specified ailments. If a claim is made during the waiting period, then the claim will be denied.
Coverage of ailments by the policy
All insurance policies explicitly mention the list of coverages and exclusions, and if the policyholder files the claim for an ailment that is specifically part of the exclusion lists, then the claim will be rejected. Therefore, one should check the list of exclusions when buying the policy to know what is not covered by the policy.
Deadline for submitting the claim
Insurance policies mention a stipulated timeframe within which the policyholder must file the claim, typically the policy allows a period of 60-90 days from the date of discharge to file the claim. Failure to comply with the aforementioned deadlines may result in the rejection of the claim. It is smart to file the claim soon after discharge. The insurer may admit the claim for justified cause of the delay in the presentation of the claim.
Insufficient/inadequate documentation
Sometimes claims, especially reimbursement claims, are denied due to missing or incorrect documents. The policyholder must submit all original documents, test reports, medical consultation letters and other required documents along with the completed claim form to avoid any problems.
To ensure smooth claims settlement, it is also strongly recommended that you choose a preferred network hospital for treatment, as you can avail of cashless facilities, you can get better rates, waiver of certain charges and benefits of other items. that are not safe in these hospitals. .
Most insurers have a wide network of hospitals integrated with them, spread across the country, and it helps to get smooth claims settlement. Even if the policyholder files a claim for reimbursement, they will not face any major problems with the settlement of the claim, as long as they have filled out the claim form in its entirety and submitted all the necessary supporting documents.
As long as a claim is allowable under the policy and is valid, the claim will be paid and the policyholder must be sure of this.
(The author is Head – Health Management Team, Bajaj Allianz General Insurance)