Common reasons for health insurance claim rejections
Facing a rejected claim can be disheartening—especially during a medical emergency. Understanding the common reasons why health insurance claims are denied can help you avoid costly mistakes and ensure smoother approvals in the future.
Here are some of the most common causes of health insurance claim rejection:
- Inaccurate information submitted: Even small errors in your name, policy number, diagnosis codes, or hospital documentation can lead to immediate claim denial. Always double-check the paperwork before submission.
- Overlooked policy exclusions: If your treatment falls under the list of exclusions in your health insurance policy—like cosmetic surgeries or certain pre-existing conditions—it may not be eligible for coverage.
- Missing pre-authorisatio: For planned surgeries or high-cost procedures, insurers often require pre-approval. Skipping this step—even unintentionally—can result in outright rejection.
- Billing and coding discrepancies: If the hospital makes billing errors like duplicate charges or wrong treatment codes, your claim can be flagged. It’s wise to ask for an itemised bill and verify it before filing.
- Non-covered or unnecessary treatments: Claims for alternative therapies, experimental treatments, or procedures deemed medically unnecessary under the policy are usually denied.
- Claims during the waiting period: Most health insurance plans have a waiting period for pre-existing diseases, maternity benefits, or specific treatments like hernia or joint replacement. If you raise a claim for such conditions before the waiting period ends, your insurer can reject it.
- Tip: Understand your policy’s waiting period clauses clearly and plan treatments accordingly. You can also compare policies with shorter waiting periods for critical needs.
- Claim request not deemed fit: Sometimes, insurers may reject claims if they feel the treatment or hospitalisation was not justified. For example, admission for minor ailments that could be managed on an outpatient basis may be seen as unnecessary.
- Tip: Always ensure your hospitalisation is medically necessary and backed by your doctor’s prescription, reports, and discharge summary.
- Policy lapse due to missed premium payments: If your policy has lapsed because of unpaid premiums, any claims made during that period will not be honoured. Even a single missed payment can make your policy inactive.
- Tip: Set reminders for premium due dates or opt for auto-debit options to keep your policy active and avoid claim rejection due to technical lapses.
Avoid surprises. Always verify coverage, documentation, and claim process in advance.
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What to do if your insurance company denies your claim in India?
- Correct the Data: If the rejection was due to incorrect or incomplete details, inform your insurer about your intent to reinitiate the claim. Review the claim form carefully, identify the error, and fill it out again with accurate information. You can also take assistance from the insurer’s customer support team to ensure there are no mistakes this time. Submitting error-free data significantly improves the chances of your claim being approved.
- Provide Proper Documentation: If the claim was denied because of missing paperwork, reapply by submitting all the required documents, including the ones that were previously left out. Ensure you attach every supporting document requested by your insurer to avoid further delays or rejection.
- Prove the Need for Hospitalisation: In cases where the insurer rejected the claim on the grounds that hospitalisation was unnecessary, you can strengthen your case by submitting your doctor’s prescription recommending admission, along with diagnostic test reports. This helps establish that hospitalisation was medically essential. Presenting clear proof can convince the insurer or TPA to approve your claim upon resubmission.
Steps to take when your health insurance claim gets rejected
A claim rejection doesn’t have to be the end of the road. With the right approach and timely action, many rejected claims can be reviewed, appealed, and even approved. Here’s a step-by-step guide to help you navigate the situation confidently:
- Start by reviewing the rejection notice: Go through the Explanation of Benefits (EOB) or the insurer’s denial letter carefully. Identify the exact reason for rejection—whether it’s missing documentation, billing errors, or an uncovered service.
- Gather supporting documents: Compile all relevant paperwork—this includes hospital bills, prescriptions, doctor’s notes, test reports, and any communication between you and the healthcare provider.
- Contact your insurance provider immediately: Call the insurer’s helpline or use their online portal to clarify the reason for denial. Sometimes, claims are rejected due to easily correctable errors like wrong codes or incomplete forms.
- File a formal appeal: If you believe the rejection was unjust or based on incomplete information, raise a formal appeal. Submit a written explanation along with the necessary medical documents and a letter from your healthcare provider if needed.
Claim denials can feel overwhelming—but you don’t have to face them alone.
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Understanding the appeals process for medical insurance claims
- Internal appeal: Start by submitting an internal appeal to your insurer, following their specific guidelines and deadlines.
- External review: If your internal appeal is denied, you may request an external review by an independent third party.
- Legal recourse: In cases of persistent denial or unresolved disputes, seeking legal assistance may be necessary to pursue further action.
