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pays for your hospital bills for diagnostics, surgery etc.

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What will happen if my health insurance claim is rejected?

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Health insurance is an important aspect of life that requires years of studious payment of Health Insurance premium. However, it comes as a rather harsh surprise to deal with the idea of Claim rejection. When you know everything about health policy, when you have paid much attention to sum Assured and when you have adhered to the stipulated terms of health insurance premium, claim rejection is the last thing that you would have planned for.

Reasons for claim rejection:

Wrong choice of health policy:

Research into claim rejection in health insurance shows that one of the major reasons tends to be the wrong choice of Mediclaim at the outset. Many people think that they have the right insurance coverages for them, or that their mediclaim is capable of satisfying their needs, only to end up with claim rejection.

Dealing with the waiting period:

Health Policy is much more than just health insurance Premium and sum assured. Reading the fine print is an important aspect of health insurance, and in many occasions, not knowing about details such as the mandatory Waiting Period involved could lead to claim rejection. Users of mediclaim need to know that they could not stake claims during the initial waiting periods, during which no claim may be entertained.

Partial or complete non-disclosure:

Misrepresentation of facts is also thought to be one of the primary reasons behind a majority of claim rejections. Since health insurance works based on what is disclosed, non-disclosure or partial disclosure of information when the health policy is purchased could have an impact in the form of claim rejection when the actual claims are made on mediclaim.

Improprieties in claim filing:

Sometimes, claim rejection may not have anything to do with health insurance premium paid or the kind of health policy purchased. Even if you knew the terms associated with health policy, a common mistake that leads to claim rejection tends to be associated with claim filing. Mistakes and omissions at the time of filing of claims, using the wrong forms to stake claims, or even delays in filing claims could lead to claim rejection.

What should you do if health insurance claim is rejected?

Keep the records:

As a preventive measure to deal with possible claim rejection, it would help to have a record of all the information that you submit when you file claims on your health policy. Get into the habit of keeping photocopies of the information that you file, since you may never know when you may need them.

Check your records:

If you already have copies of the documents submitted, you may want to see if there have been any omissions or errors in the documents you filed. If you could spot lapses, wrong information, missed details, or wrong forms, you already know the problem behind rejection of your health insurance.

Contact the insurance provider / TPA:

It is important to remember that not every claim rejection may indicate a problem with your claim. It is a definite possibility that you could deal with rejection of your mediclaim just by resorting to a first-level complaint with the TPA. You could rule out possible clerical errors or administrative instances involved in honoring your health policy, sometimes, without any need for further escalation.

File an appeal:

Claim rejection is not the be-all and end-all of the issue. If your initial contacts with the TPA have not ended in an amicable resolution, go ahead with filing an appeal with your insurance provider. If you could furnish the supporting documents that claim that the procedure you underwent was medically necessary and provide all relevant information in the form of medical proof, you could well be on the way to reversing a claim rejection on mediclaim or health insurance.