• 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
    • Max Bupa Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have my health insured with Max Bupa health insurance from last 4 years, i have a coverage value of Rs 30 lakhs for this insurance policy. My claim experience was very good and i claimed 100% of the billed amount. I have also taken the cashless treatment from this insurance policy.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Apr 26, 2018
    • Royal Sundaram Health Insurance
      "Good Policy"
      0.5 3.0/5 "Satisfactory"
      I have a health insurance policy with Royal sundaram from last 1 month, the coverage value of this insurance policy is 3 lakhs. I am not aware of the premium amount as my company pays it. I do not have claim experience so far with this insurance policy.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Apr 26, 2018
    • United India Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have my health insured with United India Insurance from last 2 years, my claim experience was very good with this insurance policy. They covered 90% of the billed amount and i am satisfied with the coverage value of Rs 3 lakhs. I am not aware of premium as my company pays it.
      Was this review helpful? 0
      , mumbai
      Reviewed on Apr 26, 2018
    • HDFC Ergo Health Insurance
      "Good Policy"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy with HDFC ERGO from last 5 years, a premium of Rs 10000 has to be paid every year for this insurance policy. My claim experience was good with this insurance. I have a coverage value of Rs 3 lakhs for this health insurance policy.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Apr 25, 2018
    • National Insurance Health Insurance
      "Health insurance with National insurance"
      0.5 3.0/5 "Satisfactory"
      I hold a Corporate health insurance from National insurance. The policy coverage will be for 3 lakhs rupees. This policy have the coverage for my family as well. There is no claim experience till now. They do have cashless and reimbursement facility.
      Was this review helpful? 0
      , bangalore
      Reviewed on Apr 25, 2018
    • review Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have my health insured with IFFCO TOKYO from last 1 year, i am happy with the coverage value of this insurance policy. I do not have claim experience so far with this insurance company. My premium amount gets auto deducted from the salary account. I have a coverage of Rs 5 lakhs for this insurance.
      Was this review helpful? 0
      , kolkata
      Reviewed on Apr 25, 2018
    • ICICI Lombard Health Insurance
      "Average Policy"
      0.5 3.0/5 "Satisfactory"
      I have my health insured with ICICI lombard from last 2 years, the coverage value of this insurance policy is very less which is Rs 1 lakh. I am not aware of the premium amount as my company pays it. I do not have claim experience so far with this insurance policy.
      Was this review helpful? 0
      , pune
      Reviewed on Apr 24, 2018
    • Star Health Health Insurance
      "Health insurance with STAR"
      0.5 3.0/5 "Satisfactory"
      I have taken health insurance from STAR HEALTH & ALLIED INSURANCE. and the premium amount is 2500 for 2.5 lakhs of policy coverage.They dont provide any cashless faculty but provide reimbursement. There is no claim experience till now. Its an individual policy.
      Was this review helpful? 0
      , chennai
      Reviewed on Apr 24, 2018
    • Bajaj Allianz Health Insurance
      "Good policy for health"
      0.5 5.0/5 "Blown Away!"
      I have taken a health insurance with BAJAJ ALLIANZ GENERAL INSURANCE and the premium i am paying was 13600 annually. The provide cashless facility and the claim experience was good. The have cashless facility almost 99% of coverage done through the insurance.
      Was this review helpful? 0
      , kolkata
      Reviewed on Apr 21, 2018
    • Religare Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have my health insured with Religare health 4 months back, i am happy with the coverage value of this insurance policy. A premium of Rs 8000 has to be paid every year for this health insurance. I do not have claim experience so far with this insurance and they cover Rs 5 lakhs for this insurance.
      Was this review helpful? 0
      , ahmedabad
      Reviewed on Apr 20, 2018
    • Religare Health Insurance
      "Good policy"
      0.5 4.0/5 "Great!"
      From RELIGARE Health i have taken the health insurance. They provide cashless facility. There is no claim experience with them. There is health check up available on the insurance policy. Its an individual policy.The customer service and response is good.
      Was this review helpful? 0
      , mumbai
      Reviewed on Apr 20, 2018
    • United India Health Insurance
      "Average Policy"
      0.5 3.0/5 "Satisfactory"
      I have a health insurance policy with United India Insurance from last 5-6 years, my claim experience was not up to the mark as they covered only 40% of the billed amount. I have a coverage value of Rs 3 lakhs and i pay a premium of Rs 3200 for this insurance.
      Was this review helpful? 0
      , surat
      Reviewed on Apr 19, 2018
    • Apollo Munich Health Insurance
      "extra ordinary experience"
      0.5 5.0/5 "Blown Away!"
      I had taken a health insurance policy from the top most private sector insurance company APOLLO MUNICH. They couriered my health card to my registered communication address. They have a good network with corporate hospitals. I had a good positive claim experience and i claimed nearly 95% of billed amount.extra ordinary experience
      Was this review helpful? 0
      , coimbatore
      Reviewed on Apr 18, 2018
    • New India Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have no claim experience so far with the health insurance, i am using this insurance from last 1-2 years and i am not aware of the premium amount as my company pays it. The coverage value of this insurance policy is 3-4 lakhs and i am satisfied with it.
      Was this review helpful? 0
      , chennai
      Reviewed on Apr 18, 2018
    • Star Health Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have my health insured with Star health from last 3 years, i am not aware of the premium amount as my company pays for the health insurance. I am happy with the coverage value of Rs 2 lakhs for this health insurance. I do not have claim experience so far with this insurance.
      Was this review helpful? 0
      , mumbai
      Reviewed on Apr 17, 2018
    • HDFC Ergo Health Insurance
      "best policy"
      0.5 5.0/5 "Blown Away!"
      I had taken a health insurance policy from the HDFC ERGO GENERAL INSURANCE. My annual premium is very reasonable by comparing with other premiums. I had a positive claim experience. The claim procedure is very easy and simple. The costumer support is good and well responsive.
      Was this review helpful? 0
      , mumbai
      Reviewed on Apr 17, 2018
    • HDFC Ergo Health Insurance
      "HDFC Ergo Health insurance"
      0.5 5.0/5 "Blown Away!"
      When i have taken the credit card from HDFC They have activated the heath insurance HDFC ERGO. The total policy coverage is for 3 lakhs. If hospitalized then i can claim upto 50000. It will covers my family as well. They do have reimbursement option as well. It will be auto debited from my salary account.
      Was this review helpful? 0
      , gurgaon
      Reviewed on Apr 17, 2018
    • ICICI Lombard Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy with ICICI lombard from last 2 years and it is one of the best insurance policy to use. They gave a coverage value of Rs 3 lakhs for this insurance. My claim experience was good and they covered 100% of the billed amount. I pay an insurance premium of Rs 16000-17000 every year.
      Was this review helpful? 0
      , jabalpur
      Reviewed on Apr 16, 2018
    • Max Bupa Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have my health insured with MAX BUPA insurance from last 1.5 years, I have a very good coverage value of Rs 4 lakhs for this health insurance. I am not aware of the premium amount as my company pays it. I have not taken any cashless treatment and there is no claim experience so far.
      Was this review helpful? 0
      , chennai
      Reviewed on Apr 16, 2018
    • Tata AIG Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have my health insured with TATA AIA insurance from last 1 month, the premium amount of this insurance is Rs 33000 which has to be paid every year. I do not have claim experience so far with this insurance and i have a coverage of Rs 60 lakhs for this insurance.
      Was this review helpful? 0
      , kolkata
      Reviewed on Apr 16, 2018
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