Why can your Health Claim be denied?

Why can your Health Claim be denied?
Written by Medhaavi Mishra

With increasing medical inflation, the need for health insurance has become pivotal in our lives. And yet, there are times when your insurer can deny your claim based on numerous impactful factors.

On a regular day, the benefits from your Health Insurance Policy should be able to sustain and indemnify your medical expenses. But, what if it doesn’t? Generally, you would invest in a Health Insurance Policy thinking that you are covered for unforeseen events in the future, right?

We get that all the insurers promise to cover you medically and fulfill the claims you’d make against your hospitalization. But, there are a few peculiar events, where your insurer can reject your claim completely.

Let us take you through a few reasons why your health insurance claim might have a possibility to be denied!

Non-Disclosure of Facts

Were you transparent enough when you were asked questions related to your health and habits? A policy is issued established on the fact that you have stated and provided all the personal and medical history details truthfully to the insurer while filling the proposal form.

Now, based on your declared information, underwriting of the policy is devised taking into consideration the risks you may or may not carry.

Health risks are a crucial aspect whilst you get your policy issued.

In all honesty, the Insurance Companies are also trying to make money while insuring you, no? Assuming you still go ahead and hide a few vital pieces of information from your insurer, what next? You can be relaxed now that you have been issued the policy. However, when the need arises and you have to file a claim, you would notice that the insurer will reject your claim based on the same facts you hid from them.

Isn’t that a foul situation for anyone to be in?

Hence, disclosing personal details, howsoever unfavorable in your interests, is utterly crucial. You might have to pay a slightly higher premium because of the ailment or habit, but at least, your claim will be indemnified, to a large extent.

Unsound Health Insurance Claim Procedure

Insurance providers are very specific and rigid when it comes down to following the prescribed steps to file a claim. Be it informing the Insurer or the TPA, seeking hospitalization at a network hospital, filling up the claim form, or gathering and presenting of the relevant medical bills and receipts.

If you misstep even one of the mentioned steps, the chances are that your insurer will deny the claim. Try and seek guidance from the insurer’s customer service or the TPA at every step of the process to make sure you leave no stones unturned.

Temporary and Permanent Exclusions

Every Health Insurance Policy has an exclusion list, which states all the waiting periods and the ailments that the policy won’t cover at all. Any claim made during the prescribed waiting period will always lead to a claim getting denied unless stated otherwise. Similarly, there usually is an extensive list of illnesses and conditions, and if you happen to suffer from any of them, the insurer will not compensate for your medical expenses.

Some health insurance policies completely exclude maternity benefits from the coverage and some impose a waiting period before you can claim benefits for pregnancy and newborn-related expenditures.

Lapsed Policy Claims

The insurer knows that there can be a delay in the payment of premiums and consequently, all the Insurance Providers do have a 30-day grace period. So, even if you falter on a premium due date, you get a safety net of another month’s time.

Now, if the Grace Period is done with and you’re still left to pay the premium, your policy will lapse for sure. And, no lapsed policy shall accept a claim request, even if you are delayed by 2 days.

Self Harm and Drug Abuse

None of the insurers will cover you for injuries that you have sustained because of intentional self-harm. Conditions and wounds caused due to attempted suicide stemming from the need to cope with pain, anger, and frustration are some of the most common examples.

Other than that, if you are an alcoholic or are involved in drugs that deteriorate your health condition severely, the insurer will refrain from processing your claim for the treatments you might have had.

Can something be done after your claim gets rejected?

Yes, there are a few ways you can file a dispute or put in a request with the insurer, if you think the claim has been rejected either because of your mistake or if you think the insurer is mistaken.

You need to follow these certain steps cautiously if you want the insurance provider to reconsider their decision and believe you on your word for the claim is genuine –

  • Read your Health Insurance Claim Form with utmost care. To be precise, check for errors in your name, date of birth, and policy number, as they are the most crucial details in the form. And, if there are any errors, inform the TPA to reopen your case at the earliest and make the insurer aware immediately as well.
  • Sometimes your claims can be rejected because of incomplete information provided by you during the filing process. In these circumstances, the TPA representative can help you right away by pulling up your details and fixing them.
  • Recheck the set of documents you had sent/attached with your claim form. See if there are any more documents needed, or if the set misses a piece of documentation like a medical bill/receipts, or if a document simply lacks attestation.

After you have gathered all the necessary supporting documents –

  • Frame a formal letter or e-mail with the statement that clearly states the reason for your claim being genuine and legitimate.
  • Attach all the paperwork without fail along with the doctor’s opinion to substantiate your claim request.
  • The insurance provider should get back to you within 30 days from writing to them. But, in case they don’t, you can approach the Ombudsman. Just make sure to write to the Ombudsman within a month’s time from the insurer’s last response.
  • Consider your intimation to the office of the Ombudsman as your last resort. And if that doesn’t work, you might have to seek legal help which will cost you more than your medical bill.

If you need help with the claiming process of your insurance or want to port to another insurance provider, Ditto’s advisors today!
Ditto offers free insurance-based consultations, answers your queries, and helps you choose your policy wisely.

About the author

Medhaavi Mishra