scorecardresearchThese five reasons could lead to the refusal of your health insurance claim

These five reasons could lead to the refusal of your health insurance claim

Updated: 21 Aug 2022, 11:19 AM IST
TL;DR.
Even online, purchasing a health insurance policy is simple, but are claims always processed promptly? It's possible for your health insurance claim to be denied for a variety of reasons. Let's go over them in more depth.
A serious medical emergency can leave a person with a huge financial hole and, most likely, costs more than their savings. The value of health insurance is now indisputable in such a circumstance.

A serious medical emergency can leave a person with a huge financial hole and, most likely, costs more than their savings. The value of health insurance is now indisputable in such a circumstance.

The number of health risks is always rising in the era we live in. A serious medical emergency can leave a person with a huge financial hole and, most likely, costs more than their savings. The value of health insurance is now indisputable in such a circumstance.

When you obtain a health insurance policy, the insurer is obligated by the terms of the contract to provide financial support in certain medical crises. The insurance policy's conditions don't just apply to emergencies; they also include routine doctor's appointments and hospital stays.

A health insurance plan can be easily purchased, even online, but are claims always resolved when they are made? A claim could be rejected for a number of different reasons. Let us discuss them in detail.

If you have exhausted your sum Insured limit

There is an sum insured involved when you choose a health insurance policy or a personal accident policy, whether it is a family floater or an individual medical coverage. The sum insured is the annual amount that you or your family have access to, depending on the plan you've chosen. If you use up all of your allowance for a given year, your subsequent cashless claims will be denied.

If you filed the claim incorrectly

When filing a claim, the policyholder must adhere to the steps prescribed by the insurance company. One of the requirements for filing a claim is notifying the insurer of the emergency, getting care at an accredited hospital, completing the necessary claim form, and attaching all pertinent receipts and reports. Your claim may be rejected if it is filed improperly or incorrectly.

If you omitted crucial information while purchasing insurance

A health insurance policy is issued with the understanding that the applicant has provided all necessary information in the proposal form honestly and accurately. The insurer conducts underwriting in order to assess the risk you pose based on the information you have provided.

You are in a perilous situation if you withhold vital information or lie about any medical problem you have. When a claim is made, the insurer investigates the circumstances surrounding it. If it turns out that you suppressed or lied about a material fact, the insurer has the right to deny your claim.

If the claims are made for the exclusions

Every health insurance policy contains a list of instances that it excludes from its coverage. These are the exclusions that are indefinitely in place, and any claim pertaining to an instance that falls within them will be rejected.

Additionally, there is a waiting time for pre-existing conditions, and some conditions are covered only once the allotted waiting period has passed. Claims for such exclusions that have a waiting period would be rejected throughout the waiting period.

If you exceed the prescribed time limit

You have a set amount of time to submit a reimbursement request under a health insurance coverage. Regarding emergency admission, the time period is 24 hours following the patient's admission. In other circumstances, it may vary depending on the type of policy you've chosen and the sort of treatment you're receiving. If you don't submit your application by the deadline, your claim may be denied.

Furthermore, keep in mind that no health insurance company may deny a claim if you have been paying your premiums for your health insurance plan for at least 8 years. This is expressly stated by the Insurance Regulatory and Development Authority of India ( IRDAI). However, keep in mind that some transparency and clearly presenting the information from your end might go a long way toward reducing the likelihood that your health claim will be rejected.

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First Published: 21 Aug 2022, 11:19 AM IST