How to Prevent Claim Rejection in Health Insurance

Ravi had diligently paid his health insurance premiums for five years, confident that he had coverage for any unexpected medical emergencies.

One day, he had a heart attack, and the doctor performed an angioplasty to remove a blockage in his arteries. While relieved to have survived this ordeal, Ravi now faces growing concerns over the hospital bill. He submits his claim to his health insurance company, hoping for a settlement process.

However, Ravi’s claim is rejected. The reason? He failed to disclose his existing condition of hypertension when purchasing the policy. 

This unfortunate scenario is all too common. According to a report released by IRDAI, health insurers in India rejected 8.61% of claims during the 2019-20 period. This means that out of every 100 claims submitted, insurers declined around 9.

So, how can you prevent claim rejections? Here are some helpful tips and practices for you to consider.

Common Reasons for Claim Rejections

Understanding the causes behind claim rejections is crucial to prevent them. Some of the reasons include:

Disclosure or Misrepresentation

This is the main reason for health claim rejections. It refers to providing incomplete information about yourself, your health, any Pre-Existing Diseases (PEDs), family history, lifestyle, or any other pertinent details during the policy application process. In the aforementioned scenario, Ravi had not informed his insurer about hypertension, a health condition that existed before he bought the policy.

Limitations

Every health insurance policy comes with exclusions and limitations that outline what is not covered under the policy. These may include certain illnesses, treatments, procedures, expenses, or circumstances. On standard, cosmetic surgeries, dental treatments, and X-ray costs might be excluded from your policy. Hence, you should review all exclusions before signing up or making a claim for an expense not covered. 

Policy Lapse

Your policy may lapse if you fail to pay your premium on time. If this happens, you will lose your coverage and the ability to make a claim. Make sure to renew your policy on time as well. They usually expire within a year.

Suspicion of Fraud 

This comes into play when your insurance provider suspects that you have attempted to mislead them in any way. For example, if you attempt to submit a claim or provide falsified or tampered documents to increase the amount of your claim, your insurer might revoke your policy.

Importance of Transparency and Timeliness

Transparency and timeliness are two factors that can help you avoid claim rejection and ensure a smooth claims process. The following are the advantages of being transparent and prompt with your insurer:

Transparency:

• Results in building trust and confidence with your insurer.
• Helps you to avoid non-disclosure or misrepresentation.
• Makes you skip policy-type mismatch issues.
• Prevents you from being suspected of fraud.

Timeliness:

• Assists in avoiding policy lapse issues that can lead to loss of coverage and claim rejection.
• Helps you prevent delays in timely reporting issues that can lead to claim rejection and reduced settlement.
• Might even result in you obtaining prior approval from your insurer for any repairs or actions that affect your claim.
• Your insurer may accelerate the assessment and settlement of your claim.

Read Policy Details Carefully

Read through your policy details and understand all terms and conditions. Your policy document serves as an agreement between you and your insurance provider, including all the information regarding coverage, benefits, exclusions, limitations, and obligations.

Purchase Plans With Good Claim Settlement Record

The last and most important recommendation is always to buy your health insurance plan from a reputed insurer. You should check the claim settlement ratio, claim repudiation ratio, insurer’s inception year, and customer reviews before purchasing health insurance. Claim rejection due to redundant reasons may impact your financial planning.

Key Takeaways

Avoiding claim rejection in health insurance necessitates diligence and awareness. Always ensure that you provide complete information to your insurer and promptly report any incidents to them. Thoroughly review your policy details. By adhering to these suggestions and adopting practices, you can avoid typical challenges and guarantee a streamlined and stress-free claims procedure. 

It is important to remember that health insurance is more than a commodity—it represents a commitment. It signifies the assurance that your insurer will be there for you when you require assistance. Therefore, you must fulfill your responsibilities to uphold this commitment and reap its fruit. With platforms such as PhonePe, managing your health insurance policy becomes all the more easy and hassle-free!