Health insurance serves as a safety net, providing financial protection against the high costs of medical care. However, encountering a rejected health insurance claim can be frustrating and overwhelming. Understanding why claims are rejected, how to address rejections, and steps to prevent future rejections are crucial for navigating the complex scenario of health insurance.
What is health insurance claim rejection?
A health insurance claim rejection occurs when an insurance provider refuses to honour a claim made by a policyholder. The insurer may decline the claim for many reasons – often due to errors in the claim submission or policy terms and conditions. A rejected health insurance claim can result in notable financial stress for individuals, especially those dealing with substantial medical costs.
Explore: How to make a health insurance claim?
Common reasons for health insurance claim rejections
There can be multiple reasons for an insurance provider to reject claims. Given below are a few common reasons for health insurance claim rejection:
- Inaccurate information: Errors in policyholder details, treatment codes, or medical records can lead to claim rejection.
- Policy exclusions: Certain treatments or services may be excluded from coverage under the policy, resulting in claim denial. One must always be aware of the exclusions under health insurance policy against which they are making a claim.
- Lack of pre-authorisation: Some insurers require pre-authorisation for specific procedures or treatments, and failure to obtain it can result in claim rejection.
- Billing errors: Mistakes in billing, such as duplicate charges or incorrect coding, can lead to claim denial.
- Non-covered services: Services not covered by the policy or deemed medically unnecessary may result in claim rejection.
Steps to take when your health insurance claim gets rejected
You can follow the steps given below when your health insurance claim gets rejected:
- Review the rejection notice: Carefully review the explanation of benefits (EOB) or rejection letter from your insurer to understand the reason for the claim denial.
- Gather documentation: Collect all relevant documents, including medical records, invoices, and correspondence with healthcare providers.
- Contact your insurer: Reach out to your insurer to seek clarification on the rejection reason and discuss potential solutions.
- File an appeal: If you believe the rejection was unjustified, file an appeal with your insurer, providing any additional information or documentation to support your case.
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.
