Medical Claim Rejection Reasons

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Introduction

There is nothing more precious than your health and life. So, access to top-notch healthcare facilities is critical during medical emergencies. A comprehensive health insurance plan covers all medical expenses and protects you against financial hardships. It saves you from the double whammy of ill health and exorbitant hospital bills.

Thus people with health coverage seek to avail of high-quality medical treatment. However, many of them may experience a rude shock when the insurer rejects their claims. Now, they have no choice but to pay the bills out of their pocket. This creates unnecessary trouble for families who may be forced to drain their savings or borrow money to foot the bill. Read on to learn more about the reasons for medical claim denials and prevent this ordeal.

List of Reasons for Health Insurance Claim Rejection

Policyholders must know why the insurer denies their claims. The top health insurance claim rejection reasons are as follows:

Faulty Claim Procedure

A health insurance policy is a legal contract between you and the insurance provider. So, you need to follow the claim procedure diligently without lapses. Instances of incomplete or inaccurate application forms are quite common. Many policyholders also fail to provide requisite documents to support their claims.

 

Insurers also reject a claim if there is any undue delay in filing a claim by the policyholder. Generally, the claims have to be filed within 60 to 90 days of discharge from the hospital. Any delay inevitably leads to the denial of your claim request. Please check and confirm the claim procedure with your insurer to avoid this situation.

Misrepresentation of Facts

Apart from genuine mistakes of omission and commission, many people may misrepresent or conceal material facts. They may not provide a true picture of their health, age, or income to save on premiums. The supporting documents may not be authentic at times. This results in the rejection of claims by the insurer when they discover the acts of mischief perpetrated by a policyholder.

Pre-Existing Diseases

A policyholder may suffer from one or more health conditions when purchasing the medical policy. These are known as pre-existing diseases, and insurers typically do not cover them. This ensures that people do not exploit insurance companies by filing claims for diseases that exist before purchasing health insurance.

 

Insurers cover pre-existing diseases after the completion of a waiting period. Policyholders in the UAE must wait for at least six months to claim insurance benefits regarding these diseases. So, claims filed for pre-existing diseases before the completion of the waiting period shall be denied by the insurer.

Policy Exclusions

The policy documents specify certain conditions or situations for which the insurer shall not provide coverage. These are known as policy exclusions. The list includes self-inflicted injuries, accidental injuries due to intoxication or adventure sports, driving without a valid license, etc. Most health insurance plans refuse to accept claims (except for accidents) for the first 30 days after you purchase a policy.

 

Policyholders should read the policy documents in detail before they sign up for health insurance. It is advisable to contact the insurer to clarify your doubts and prevent claim rejections later.

Policy Expiry

A health insurance policy has a validity of one year, and it expires at the end of this period. Failure to renew upon expiry leads to the lapse of the policy. Subsequently, you will not be eligible to claim any benefit under the said policy. Many policyholders may file a claim without being aware that the policy has expired. This leads to the rejection of claims by the insurance company.

 

Policyholders must take care to renew their policies before the due date of expiry to enjoy continuous coverage. Renewal on time also prevents policy lapse and offers you other benefits.

How to Avoid the Health Insurance Claim Rejection?

If policyholders are aware of health insurance claim denial reasons, it becomes easy to take suitable precautions and avoid needless hassles. The following suggestions may be helpful in this regard.

Read the Policy Document Thoroughly

One of the primary reasons for claim rejections is ignorance or negligence of policyholders. Most of them are not aware of the terms & conditions and scope of coverage of the policy. A thorough study of the policy documents is essential to avoid any confusion. Insurance companies also provide you with a free look period of 15 to 30 days to cancel the policy if you are not satisfied with it.

Make Complete Disclosure of Material Facts

Insurers often deny the claims if policyholders fail to make an accurate and complete disclosure of all material facts. Information about your age, health condition, income, occupation, etc., must be correctly disclosed. Any change in the situation must be duly updated. This may result in a nominal increase in premiums. But you will have certainty and peace of mind that your claims shall be admitted by the insurer.

Avail of Medical Treatments With Caution

Many people may opt for surgeries, therapies, or hospital stays because they have insurance coverage. The healthcare providers may encourage them to do so to drive their business. There is a high chance that these claims will be rejected by the insurer. Hence, it is advisable to be cautious and choose treatments only if they are essential.

Select Hospitals Within the Network

Every insurance company has a network of authorized healthcare providers to offer hassle-free treatment to their customers. The insurers may reject claims if treatments are availed in unauthorized centres or outside the specified territory of coverage. Policyholders should stick to this hospital network to avoid difficulties in claims processing.

Go for Comprehensive Coverage

Many people end up buying basic plans to save on premiums. These plans do not cover a wide spectrum of health conditions and offer basic coverage. The policyholders should be aware of this nitty-gritty while purchasing the policy. They should opt for comprehensive plans to avoid claim rejections.

Select a Reputed Health Insurance Provider

An effective tip to avoid claim rejection is to deal only with highly respected insurance companies with good claim settlement ratios. Conducting proper market research and seeking feedback from close associates can help you select the right health insurance partner.

Frequently Asked Questions on Health Insurance Claim Rejection

An excess claim is one of the primary medical claim rejection reasons. The sum assured is the maximum amount you can claim in any policy year. Any claim beyond this amount shall be rejected by the insurance company unless you take a fresh policy after exhausting the limit on the earlier policy.

Yes. Advances in medical technology have significantly shortened several treatment procedures. Treatments for hospitalization less than 24 hours are covered under daycare procedures in health insurance. This is beneficial for treatments such as dialysis, cataracts, chemotherapy, fracture surgeries, etc., that now require shorter hospital stays.

You can resubmit your claim by making the necessary changes in forms and documents. Please wait for about 30 days for the insurer to address your issue. You can approach the Insurance Ombudsman if the issue is not resolved satisfactorily or the insurer fails to respond to your request.