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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
    • HDFC Ergo Health Insurance
      "GOOD SERVICE"
      0.5 4.0/5 "Great!"
      I haev taken the health insurance policy with the HDFC ERGO GENERAL INSURANCE but i have not used this policy, i have not experienced with claim with this policy. I am holing this policy since from last 2 years. The medical coverage is for 5 lakhs where the premium i pay 7600k.
      Was this review helpful? 1
      , jaipur
      Reviewed on Nov 19, 2018
    • SBI General Health Insurance
      "Good insurance"
      0.5 5.0/5 "Blown Away!"
      My company has provided the health insurance policy with SBI General. They have given a coverage value of Rs. 5 lakhs. My entire family has been covered in this policy. I had a claim experience twice. I had submitted the documents to my company, they will proceed the claim. I have received the claim amount of Rs. 2 lakhs. Most of the major hospitals has been covered in this policy.
      Was this review helpful? 0
      , chennai
      Reviewed on Nov 18, 2018
    • Future Generali Health Insurance
      "Good service"
      0.5 4.0/5 "Great!"
      I have a health insurance with Future Generali Insurance from long time, i am not aware of the premium amount as it is to get auto debited on yearly bases and I do not have any claim experience but in terms for the features it is a good policy to have. It has been a very good experience with the Future Generali.
      Was this review helpful? 0
      , kolkata
      Reviewed on Nov 18, 2018
    • Star Health Health Insurance
      "Excellent policy"
      0.5 4.0/5 "Great!"
      I hold a health insurance policy with Star. This policy is taken for my family. They have given me a coverage amount of 3.5 lakhs. They have wide range of hospitals in my locality. I pay the premium amount of Rs. 11500. They are giving a cashless treatment facility anyway i had no claim experience with this policy
      Was this review helpful? 0
      , new delhi
      Reviewed on Nov 18, 2018
    • Oriental Insurance Health Insurance
      "Excellent"
      0.5 4.0/5 "Great!"
      I have a health insurance policy with Oriental which was provided by company.It is for entire family and policy coverage for per person is 2.5L.There is no claim experience. They have good network of hospital for the cashless facility. They cover all types of minor, major diseases and critical illness.
      Was this review helpful? 0
      , chennai
      Reviewed on Nov 17, 2018
    • ICICI Lombard Health Insurance
      "Good"
      0.5 4.0/5 "Great!"
      My company has provided me a health insurance policy with ICICI Lombard. Its been 2years now. It covers for entire family and policy coverage is 3L per person. There is no claim experience but I heard the claim process was good. Am not aware of the benefits.
      Was this review helpful? 0
      , chennai
      Reviewed on Nov 17, 2018
    • Religare Health Insurance
      "Excellent service"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy from the Religare Insurance company. I am paying a premium for a per year. I do not have any claim experience with this policy. Overall it has been a smooth experience with the policy so far. I'll have to wait and see how they respond to my request in future.
      Was this review helpful? 0
      , new delhi
      Reviewed on Nov 16, 2018
    • HDFC Ergo Health Insurance
      "GOOD SERVICE"
      0.5 5.0/5 "Blown Away!"
      I am using the health insurance policy with the HDFC ERGO GENERAL INSURANCE from past two years where i have no claim experience with this policy also added on that the premium i pay seven thousand rupees per year. The medical coverage is for six lakhs for complete family.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Nov 16, 2018
    • HDFC Ergo Health Insurance
      "GOOD SERVICE"
      0.5 5.0/5 "Blown Away!"
      I am using the health insurance policy with the HDFC ERGO GENERAL INSURANCE from past two years where i have no claim experience with this policy also added on that the premium i pay seven thousand rupees per year. The medical coverage is for six lakhs for complete family.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Nov 16, 2018
    • Religare Health Insurance
      "Necessary policy for all family"
      0.5 4.0/5 "Great!"
      I have no claim experience with Religare health insurance policy. I have purchased the policy 1 month before. They have offered me a coverage value of 5 lakhs. I have taken the policy for my family. I have no idea about the list of hospital. They are providing the cashless facility. I pay the premium of Rs. 11700.
      Was this review helpful? 0
      , faridabad
      Reviewed on Nov 16, 2018
    • Apollo Munich Health Insurance
      "Excellent service"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy with Apollo Munich, this policy cover accident claim and there customer support team have explain me about this policy and the premium i pay 25,000-30,000 per year it nominal, i pay through on line, till now there service was good.
      Was this review helpful? 0
      , noida
      Reviewed on Nov 16, 2018
    • HDFC Ergo Health Insurance
      "EXCELLENT"
      0.5 5.0/5 "Blown Away!"
      I have been using my health insurance policy with the HDFC ERGO GENERAL INSURANCE and the premium i am paying six hundred and thirty five rupees per month also it gives the coverage up to one crore rupees. It is a corporate policy, i am using from past 10 years but i had no claim experience.
      Was this review helpful? 0
      , bhubaneshwar
      Reviewed on Nov 16, 2018
    • Cigna TTK Health Insurance
      "Average"
      0.5 4.0/5 "Great!"
      I have chosen Health insurance with Cigna TTK. They provided me a cashless facility and reimbursement for my doctor bills. I have taken the policy for my entire family. I pay yearly 10K as a premium through ECS. The claim experience is excellent and the reimbursement was immediate. The policy coverage for me is 5L and rest of family members is 3L. They have more network of hospitals but they pay more attention on the medical bills.
      Was this review helpful? 0
      , thane
      Reviewed on Nov 15, 2018
    • HDFC Ergo Health Insurance
      "Average service"
      0.5 3.0/5 "Satisfactory"
      I have been using HDFC ERGO health insurance for while , I never had any claim experience with the policy. I will have to wait and see how they respond to their claim requests in future, overall service was good it cover accidental policy and they charge nominal premium amount.
      Was this review helpful? 0
      , anantapur
      Reviewed on Nov 15, 2018
    • Reliance General Health Insurance
      "Good Policy"
      0.5 5.0/5 "Blown Away!"
      I have a company provided health insurance with Reliance, i am not aware of the premium amount as my company pays it. There was no claim experience so far with this insurance policy. This policy has a coverage value of Rs 4 lacs.
      Was this review helpful? 0
      , mumbai
      Reviewed on Nov 15, 2018
    • National Insurance Health Insurance
      "Excellent Service"
      0.5 5.0/5 "Blown Away!"
      This insurance policy has been taken through the company which i am working, the premium amount has been taken every month and it was a good service which they had been making so far. I had two times availed the claim through them and the method in getting the claim has also been good.
      Was this review helpful? 0
      , gandhidham
      Reviewed on Nov 14, 2018
    • HDFC Ergo Health Insurance
      "Recommendble Top up policy"
      0.5 5.0/5 "Blown Away!"
      I have done health policy top up with HDFC Ergo, the customer service is also very good. There is no processing fee for the top up, they gave me the medical amount Rs. 12 lakhs for entire family its for 3 person, I don't have claim experience. They are covering major or minor but for waiting period for pre existing is three years.
      Was this review helpful? 0
      , hyderabad
      Reviewed on Nov 13, 2018
    • HDFC Ergo Health Insurance
      "Good"
      0.5 4.0/5 "Great!"
      I already a health insurance with HDFC Ergo. I am satisfied with the benefits. The policy coverage is one year. It covers only minor disease. There is no claim experience. They provide a good network of hospitals for the cashless treatment. I don't get any reminder call for the policy renewal.
      Was this review helpful? 0
      , panipat
      Reviewed on Nov 13, 2018
    • National Insurance Health Insurance
      "Very low premium policy"
      0.5 4.0/5 "Great!"
      I have not used the health insurance for any kind of claim services. The health insurance policy from National has been issued from my organization. I have called the customer care service for a normal enquiry and the response was good. They have given me a coverage value of Rs. 5 lakhs and all the family members of mine is included in this policy.
      Was this review helpful? 1
      , dehradun
      Reviewed on Nov 13, 2018
    • Royal Sundaram Health Insurance
      "Good Experience"
      0.5 4.5/5 "Excellent!"
      I have two claim with Royal Sundaram, it was hassle free. I need to submit few documentation the process was quick. I got the reimbursement I didn't get the cash less hospitalization. On my nearest place there is no hospital which they got tie .
      Was this review helpful? 0
      , bangalore
      Reviewed on Nov 12, 2018
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