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  • How to Deal with a Health Insurance Claim Rejection?

    We often do not take wise decisions, by simply being ignorant to details and believing that some cosmic power will take care of us at all times. These circumstances lead us to a hell-hole such as the claim rejection of our health insurance. It might sound dramatic to people who are reading this as a safety measure but for those who have already experienced it and are seeking help, realize the real-life drama in the situation. So, it is important to understand the circumstances under which a claim can be rejected but at the same time it is also important that one understands the preventive measures. This is more important than the curative measures that can be taken for obvious reasons.

    Claim Rejection Circumstances:

    • Particular ailment against which the claim is being made is not covered under your medical insurance policy.
    • The form for the claim has not been filled properly.
    • The procedure was not required by the insured, medically.
    • The claim has not been filed in the correct time-frame, mentioned as per the policy.

    Prevention of Health Insurance Claim Rejection:

    Keep the following in mind about your health insurance policy to never have to deal with this again:

    • Always make copies of all the documents that you submit with the claim form for your insurance policy, to the TPA as measure of future reference.
    • Make sure that you go through the policy wordings along with terms and conditions, especially exclusions, deductibles and claim process more than anything else along with the benefits of the policy.
    • Make sure that you submit the claim request before 30 days from the date of hospitalization.
    • You must send all the medical records to the TPA. In the case of post hospitalization costs incurred the details and submission must be done within ninety days from the date of hospitalization.
    • Always double-check the insurance claim form for accuracy. (Keep multiple forms in hand incase you need to fill it again before submission)
    • Also gather enough information and proof such as doctor’s prescriptions, etc. and submit or post it to the TPA.

    What Needs to Be Done?

    Even after a claim rejection, an insurance company may reconsider your claim keeping in mind that you are able to convince the insurer that your claim is genuine. But you first need to know why it was rejected, since you need to take the next steps, accordingly. But once you know the reason, here is what you have to do:

    • See through your medical insurance claim form, submitted to the insurance company. The most important things here are the names and your policy number. If there are errors in reporting these, the TPA has to be informed to reopen the case as well as the insurer has to be clearly made aware of the error.
    • Some claims are rejected due to errors in the system caused by insufficient information provided by the claimant. The TPA representative can help you out with the solution then and there also making sure that you record details about this conversation as well as document it if possible.
    • You must check the documents sent with the claim form and whether any mistakes have been made in the form of insufficient or incorrect documentation or even lack of attestation.
    • If you figure out what is the problem it can be cleared by providing sufficient documents with correct details and attestation.
    • If the reason for rejection is medical procedure deemed unneccessary, get sufficient opinion of licensed medical practitioners to prove your claim.
    • Once you have all the documents ready supporting your claim:
      • Write and send a formal letter with the statement that includes reason for claim being genuine or valid.
      • Attach appropriate documents along with medical opinion of the licenced medical practitioner for claim substantiation.
      • Note, that multiple appeals for the claim validation can be made.
      • If the insurer does not respond to your claim in 30 days you can approach Ombudsman. This organization allows you to submit a written complaint at the Office of insurance Ombudsman within thirty days from the health insurer's response.

    The office of Ombudsman is your last resort to get your claim validated. Beyond that you might need legal aid which will cost you more than your medical bill in most cases. Hence, make sure you have a valid claim and have sufficient supporting documents.

    GST rate of 18% applicable for all financial services effective July 1, 2017.

    Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.

    Health Insurance Claim Rejection Reviews

  • Page 1 of 50 1 2 3 4 5
    • Star Health Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy with Star health from last 15 years and it is a good policy. It is a family policy with the coverage value of Rs 7 lakhs for this insurance. I have no claim experience so far from this insurance and i pay a premium of Rs 4000 for this insurance.
      Was this review helpful? 0
      , chennai
      Reviewed on Jul 18, 2018
    • ICICI Lombard Health Insurance
      "Good Service"
      0.5 4.0/5 "Great!"
      I've an employer provided health insurance policy with the ICICI Lombard. The company is paying the premium. It offers of a coverage of 2 lacs for me annually. I do not have any claim experience with the policy. So far there hasn't been any issues with the policy. I'll have to wait and see how they respond to my claims in future if I'll have any.
      Was this review helpful? 0
      , bangalore
      Reviewed on Jul 17, 2018
    • review Health Insurance
      "Not satisfied"
      0.5 1.0/5 "Really Bad"
      I took health insurance from Iffco tokio health insurance . I have choose this insurance mainly because of convincing premium amount . I have closed this insurance as they told it cover pre disease coverage . During claim process , there is no proper response from the customer service and response .
      Was this review helpful? 0
      , vadodara
      Reviewed on Jul 17, 2018
    • New India Health Insurance
      "Good Service"
      0.5 4.0/5 "Great!"
      I've a health insurance policy which is provided by the employer in partnership with the New India Insurance . The company is paying the premium, so far there hasn't been any claim experience with the policy. It offers 10 lacs hospitalization coverage and a whopping 1 Crore accidental benefits. Considering the features and benefits it is recommendable health insurance policy to have.
      Was this review helpful? 1
      , mumbai
      Reviewed on Jul 16, 2018
    • Bajaj Allianz Health Insurance
      "Useful Service"
      0.5 4.0/5 "Great!"
      I've an employer provided insurance policy with the Bajaj Allainz. The company is paying the premium, I do have a claim experience with the policy where I claimed 100% amount needed for the treatment. It was a cashless treatment and the whole process was smooth and hassle free.
      Was this review helpful? 0
      , new delhi
      Reviewed on Jul 16, 2018
    • National Insurance Health Insurance
      "Good Service so far"
      0.5 4.0/5 "Great!"
      I've a health insurance policy with the National Insurance. It offers an annual Coverage of 3 lacs, the policy covers me and my parents and I do not have any claim experience with the policy so far. I never had any issues with their services.
      Was this review helpful? 1
      , gurgaon
      Reviewed on Jul 14, 2018
    • Reliance General Health Insurance
      "Good Service"
      0.5 5.0/5 "Blown Away!"
      I've been using the Health Insurance policy from the Reliance General Insurance. The company is paying the premium. The policy covers me and my parents. The policy offers an annual coverage of 5 lacs for me and 2 lacs for my parents. So fat I do not have any claim experience with the policy.
      Was this review helpful? 1
      , bangalore
      Reviewed on Jul 14, 2018
    • HDFC Ergo Health Insurance
      "Good Service"
      0.5 5.0/5 "Blown Away!"
      I've an employer provided health insurance policy with the HDFC Ergo. It offers an annual coverage 5 lacs, the company is paying the premium. I do have any claim experience with the policy. I have claimed this policy two times for me and wife both they approved. The claim processing was really easy and they settled almost 30000.
      Was this review helpful? 0
      , pune
      Reviewed on Jul 14, 2018
    • Max Bupa Health Insurance
      "Don't buy health insurance from Max Bupa"
      0.5 0.5/5 "Unacceptable"
      I have taken policy for brother. while playing he suffered from knee injury. During hospitalization doctor suggested for ligament operation. After that we applied for cashless but max bupa rejected cashless and suggested for reimbursement. After hospitalization we submitted all claim document. max bupa send message that within 21 days claim will approved. Now after 40 days also claim is not approved and showing Suspense status . after that i checked review from many website, i come to know that max bupa claim ration is zero. This is fake company who not settle any claim. Below are my claim details: Claim Number: 339012 Final Status: Suspense Claim Decision Date: Saturday, June 9, 2018 12:00 AM
      Was this review helpful? 1
      , pune
      Reviewed on Jul 12, 2018
    • Star Health Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy with Star health from last 7 years and it is one of the good insurance policy. I pay a premium of Rs 10000 for this insurance and it is a family heath policy. My claim experience was good and i have claimed 2 times. The coverage value was 90% and it was a cashless treatment.
      Was this review helpful? 0
      , ahmedabad
      Reviewed on Jul 12, 2018
    • United India Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have my health insured with United India Insurance from last 15 years, i am happy with the coverage value of this insurance policy. I have no claim experience so far with this insurance policy. This is a family policy so the coverage value is Rs 3 lakhs.
      Was this review helpful? 0
      , coimbatore
      Reviewed on Jul 12, 2018
    • Reliance General Health Insurance
      "Claim not clear & totaly judh bol rahe hai.."
      0.5 0.5/5 "Unacceptable"
      Rejection Letter of 90618616 00 Policy No : 12371716 Reason INSURED IS SUFFERING FROM HEADACHE PRIOR TO POLICY INCEPTION AND SAME WAS NOT DISCLOSED. HENCE CLAIM IS REPUDIATED UNDER NON-DISCLOSURE. But total false.. Hame phale koi bimari nahi thi Plz take action...
      Was this review helpful? 0
      , gurgaon
      Reviewed on Jul 11, 2018
    • review Health Insurance
      "Good to take the Health insurance policy"
      0.5 4.0/5 "Great!"
      I have a claiming experience. There is plenty of hospitals covered in Hydrabad area. The claiming experience is good and it was done within 15 days. I claimed the maximum amount of Rs. 25000 till now and i can claim upto 5 lakhs for me and my family. Cashless treatment facility is also treatment. The company will take care of premium amount and all.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Jul 11, 2018
    • ICICI Lombard Health Insurance
      "Good Service"
      0.5 3.5/5 "Pretty good"
      I've a health insurance policy from the ICICI Lombard which is provided by the Company. The company is paying the premium. It covers almost all treatments, I do not have any claim experience with the policy. I'll have to wait and see how they respond to my claim in case if I'll have any.
      Was this review helpful? 0
      , mumbai
      Reviewed on Jul 11, 2018
    • Bajaj Allianz Health Insurance
      "Good Service"
      0.5 4.0/5 "Great!"
      I've been using the Health insurance policy from Bajaj Allianz for a while now. The Experience is good, don't have any claim experience. I pay a premium of 8000 Per year. I never had any claim experience with the policy so far. When considering the features it is a good policy to have.
      Was this review helpful? 0
      , bangalore
      Reviewed on Jul 10, 2018
    • Star Health Health Insurance
      "Average Policy"
      0.5 3.0/5 "Satisfactory"
      I have my health insured with Star health from last 2 years, i am not aware of the premium amount as my company pays it. It is a family health policy and the coverage value is Rs 4-5 lakhs. My claim experience was not up to the mark as they covered only 80% and it was a cashless treatment.
      Was this review helpful? 0
      , mumbai
      Reviewed on Jul 10, 2018
    • HDFC Ergo Health Insurance
      "Very Good health insurance policy"
      0.5 5.0/5 "Blown Away!"
      I have not used the claim for the policy. The benefits is excellent with HDFC Ergo. I can claim the policy upto 3 lakhs if its exhausted i can avail more than 6 lakhs. I used to pay the premium of Rs. 3500 per years. The cashless treatment is available and its a ax benefitable policy. I have already recommended many of my friends
      Was this review helpful? 0
      , mumbai
      Reviewed on Jul 05, 2018
    • ICICI Lombard Health Insurance
      "Good Service"
      0.5 4.0/5 "Great!"
      I've been using the ICICI Lombard health insurance policy for a while. This policy is for me and my mother. I never had any claim experience with the policy. Overall I never faced any issues with their services. I'll have to wait and see how they respond to my claims in future.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Jul 04, 2018
    • New India Health Insurance
      "Good health insurance policy"
      0.5 5.0/5 "Blown Away!"
      I never called the customer care service of New India insurance people. I have a claim experience twice. It is easy to claim by using the New India. I can claim upto 1 lakhs since the coverage amount for the same. I have taken this insurance for my family also. I can avail a cashless treatment. They covered everywhere means most of the hospitals in the city. I used to pay the premium of Rs. 22000 per year.
      Was this review helpful? 0
      , chennai
      Reviewed on Jul 02, 2018
    • New India Health Insurance
      "Awesome insurance company"
      0.5 5.0/5 "Blown Away!"
      My company provided me the health insurance. I claimed this policy many times. They are very simple and accessible in all the places. I always go through my company portal to get things done. They have hotline number to reach easily. There very good hospital mentioned in the list. The customer care response is also good. First of all, i have to admit in the hospital, the limit is 2 lakhs. For any higher hospitalization, then i can avail a claim of Rs. 12 lakhs. My family members also added in this policy
      Was this review helpful? 0
      , thane
      Reviewed on Jul 02, 2018
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