Top 7 reasons your health insurance claim gets rejected

Introduction

Why do we take health insurance, when it is useful to us in any medical emergency, but in such a situation, when the claim is rejected, we feel very regretful that we had taken it. Still, it did not come in handy on time. Then it is useless to take it, it is not at all like that, more important than taking health insurance is how it works.

In this article, we will try to understand all the aspects as to why health insurance claims are rejected. According to the MINT ARTICLE, if there are 100 cases for the claim, 3/4 i.e. 75% of the claims are rejected by the health insurance companies due to various reasons, out of which 18% of the claims are due to not completing the waiting period, 25% Claims are rejected because the ailments are not covered, approximately 5% of the claims are rejected because the claims documents are not properly filled, and 25% of the claims are rejected because of non-disclosure i.e. revealing the illness before taking the policy. what the insured person did not disclose. information credit : https://www.livemint.com/money/personal-finance/75-of-health-insurance-claims-rejected-due-to-limited-understanding-analysis-11700803190145.html

There are many reasons for health insurance claims being rejected, I have told about some important reasons and explained them in a sequential manner:-

Admission not justified

• That means there was no need for hospitalisation, yet he was admitted. Now let us understand this with an example, if an insured person is admitted to the hospital for fever and his temperature is less than 102 °F. The insurance company will reject the claim and will mention the reason “Admission Not Justified” because insurance companies, 102 °F considers minimum body temperature as fever. Insurance companies do not provide cover even for normal OPD unless you are admitted to the hospital for at least 24 hours and this hospitalisation should not be valid as per the insurance companies, but if you are not getting relief from any OPD. Or if you are not recovering completely then you can get admitted to the hospital and you also get a claim for OPD for the treatment for which you are admitted to the hospital

Non- Disclosures

• In health insurance, most of the claims are rejected for this reason, the insurance business is of “Utmost the Good Faith”, that is, you have to give correct and complete information about your health to the insurance company, such as any surgery, Any current medical condition (such as Asthma, BP, Cholesterol & Diabetic, any other medication or any medicine) Any kind of Hospitalisation, Any Accident Injury of any kind whether you have been admitted to the hospital due to an accident or not. You must inform your Insurance Advisor & Insurance Company. Let us assume that you have not disclosed any medical history and at the time of hospitalization you have disclosed your medical history to your treating doctor, your insurance claim will be rejected.

Discrepancy in Medical Documents

• Such mistakes can happen at any stage, such as not submitting authentic medical records of some chronic disease (PED) by the insured person, some clerical mistakes by the TPA desk of the hospital or the hospital deliberately exceeding the tariff rate. Asking for approval, not sending any necessary documents, not getting verified from the treating doctor etc. To avoid this kind of problem, please contact your consultant

Congenital Disease

• There are also two types of congenital diseases, the first of which is genetic and can be inherited from ancestors and external congenital disease, generally, this is not covered, and according to the plan, you can check in the policy wording. From time to time, the Insurance Regulator (IRDA) keeps issuing circulars for this, about which you can also know from your consultant. Some examples are Type I diabetes, congenital heart disease, cerebral palsy, and Down syndrome, e.g. https://www.pregnancybirthbaby.org.au/what-is-a-congenital-disorder)

Permanent Exclusions

• Diseases/treatment procedures for which no claim is received are kept in Permanent Exclusions. Such as – any kind of cosmetic surgery, hair transplant, experimental treatment, self-harm, abortion, any kind of dangerous activity, breaking any law, indulging in any kind of fraud, any kind of food supplements etc., my advice is this. You must check the policy wording once to see whether it is in this category.

Waiting Periods

• As in any retail health insurance plan, some waiting periods are also applicable, such as the treatment of Accidental Injury is applicable from Day 1 of the implementation of the policy, for any serious illness of any kind, 30 days of fever, epidemic etc. Days later, some specific surgeries, and medical treatment after 24 months and if there is already a disease, then there can be a waiting period of 24, 36 or 48 months. This waiting period for PED is as per the plans, so check this also once. It is necessary to do.

Blacklisted Hospital

• The Insurance Company agrees with the Hospitals and decides the tariff, also sets some conditions according to the treatment and if the hospitals do not follow the prescribed conditions, then the Insurance Company can cancel the agreement and in case of fraud, the hospital can also be blacklisted. The insurance company keeps updating it on its website from time to time. In such hospitals, the claim is not available even for treatment. If there is any medical emergency, then some part of the claim can be received. My advice is that if possible, you should go to the listed hospital only.

Conclusion

I hope that after reading this article, you have come to know about what are the reasons for health insurance claims, this gives us information that just taking it is not enough, how does it work? There should also be information, friends, share this article as much as possible and give your feedback as to how you liked the article and on which topic an article is required. Thank you!