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.
Pro tip: Before hospitalisation, review your plan’s exclusions to compare policies with minimal restrictions and broad treatment coverage. Choose plans from leading insurers
Missing pre-authorisation
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.
Avoid surprises. Always verify coverage, documentation, and claim process in advance.
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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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Also read: What is mediclaim insurance?
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.
