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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
      "Good overall"
      0.5 5.0/5 "Blown Away!"
      I have taken a health insurance policy from Star health insurance. It is for my family and I. Till date I have not had a claim experience. The medical coverage is for six months. The premium is not costly. The process to buy the policy in smooth and easy.
      Was this review helpful? 0
      , bangalore
      Reviewed on Sep 22, 2018
    • HDFC Ergo Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have a health insurance policy with HDFC ERGO from last 2 years, i am happy with the coverage value of this insurance policy. I have no claim experience so far with this insurance policy. A premium of Rs 6000 has to be paid for this insurance and the coverage value is Rs 3-4 lacs.
      Was this review helpful? 0
      , vadodara
      Reviewed on Sep 17, 2018
    • Reliance General Health Insurance
      "Average Service"
      0.5 3.0/5 "Satisfactory"
      I've a health insurance policy with the Reliance General Insurance. I am paying a premium of 27000 per year. It is for the entire family. There hasn't been any claim experience so far. I will have to wait and see how they respond to my requests in future if I will have any.
      Was this review helpful? 1
      , hyderabad
      Reviewed on Sep 15, 2018
    • New India Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      My health insurance is with New India Assurance from last 1 year, i am not aware of the premium amount as my company pays it. I have no claim experience so far with this insurance policy and the coverage value is Rs 2 lacs for individual.
      Was this review helpful? 1
      , bangalore
      Reviewed on Sep 14, 2018
    • Apollo Munich Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have a health insurance policy with Apollo Munich from last 7-8 years, i have no claim experience so far with this insurance policy. I pay a premium of Rs 12000 for this insurance policy and the coverage value is Rs 5 lacs for this policy.
      Was this review helpful? 0
      , pune
      Reviewed on Sep 12, 2018
    • Cigna TTK Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have a health insurance policy with CIGNA TTK from last 2 years, i am happy with the coverage value of this insurance policy. I pay a premium of Rs 12000 for this insurance policy. I have no claim experience so far with this insurance and the coverage value of Rs 4.5 lacs.
      Was this review helpful? 1
      , bangalore
      Reviewed on Sep 12, 2018
    • Max Bupa Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have a health insurance policy with MAX BUPA from last 6 years, i am happy with the coverage value of this insurance policy. I have no claim experience so far with this insurance and i get no claim bonus every year. The coverage value for this insurance is Rs 15-20 lacs.
      Was this review helpful? 0
      , faridabad
      Reviewed on Sep 12, 2018
    • Star Health Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      My health is insured with STAR health from last 1year and it is a good policy to use. It is a family policy where the coverage value is Rs 3 lacs per individual. I do not have claim experience with this insurance and i pay a premium of Rs 15000 for this insurance.
      Was this review helpful? 1
      , coimbatore
      Reviewed on Sep 12, 2018
    • Religare Health Insurance
      "Best policy"
      0.5 5.0/5 "Blown Away!"
      I have a health insurance policy with Religare from last 1.5 years, a premium of Rs 14000 has to be paid for this insurance policy and it is a family coverage. My claim experience was very good and they covered 100%. Coverage value is Rs 5 lacs +5 lacs (auto refill) for this insurance.
      Was this review helpful? 0
      , ahmedabad
      Reviewed on Sep 12, 2018
    • HDFC Ergo Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have my health insured with HDFC ERGO from last 1.5 months, i am happy with the coverage value of this insurance policy. A premium of Rs 6000 has to be paid for this insurance policy. I have no claim experience with this insurance the coverage value is Rs 5 lacs.
      Was this review helpful? 0
      , palanpur
      Reviewed on Sep 12, 2018
    • ICICI Lombard Health Insurance
      "Normal Service"
      0.5 4.0/5 "Great!"
      I've a health insurance policy with the ICICI Lombard. I am paying low premium, there hasn't been any claim experience with the policy so far. Considering the premium I pay it has been a normal experience with the policy so far.
      Was this review helpful? 1
      , udaipur
      Reviewed on Sep 11, 2018
    • ICICI Lombard Health Insurance
      "Good Service"
      0.5 5.0/5 "Blown Away!"
      I've a health insurance policy with the ICICI Lombard, I am paying the premium and I do not have any claim experience with the policy so far. I'll have to wait and see how they respond to my claim requests in future. It has been a hassle free experience so far.
      Was this review helpful? 0
      , bangalore
      Reviewed on Sep 11, 2018
    • Star Health Health Insurance
      "Start Health Insurance Fraud"
      0.5 0.5/5 "Unacceptable"
      My father purchased Star health insurance for family safety and was paying premium from last 2 years but when time came insurer refused to give claim stating that throughout the hospitalization and all investigation reports are within normal limits. My brother was admitted in family hospital delhi for 24 hours, doctors diagnosed him and billed approx 13500.
      Was this review helpful? 3
      , new delhi
      Reviewed on Sep 08, 2018
    • Star Health Health Insurance
      "Satisfactory"
      0.5 5.0/5 "Blown Away!"
      Star health is good in the health insurance policy. The medical coverage is good. It is for my family and I and fortunately I had not had a claim experience til date. The premium is normal and there are good benefits too. There is a no claim bonus too.
      Was this review helpful? 1
      , secunderabad
      Reviewed on Sep 06, 2018
    • ICICI Lombard Health Insurance
      "Normal Service"
      0.5 4.0/5 "Great!"
      I've a health insurance policy with the ICICI Lombard. I am paying a premium 280 per month, for me and family. I do not have any claim experience with the policy. The annual coverage 2.5 Lacs. It has been a hassle free experience with the policy so far.
      Was this review helpful? 0
      , bangalore
      Reviewed on Sep 05, 2018
    • Star Health Health Insurance
      "Good Policy"
      0.5 5.0/5 "Blown Away!"
      I have my health insured with Star health insurance from last 6 months, i am not aware of the premium amount as my company pays it. The coverage value for this insurance policy is Rs 3 lacs and there was no claim experience so far with this insurance policy.
      Was this review helpful? 1
      , hyderabad
      Reviewed on Sep 05, 2018
    • HDFC Ergo Health Insurance
      "Best Policy"
      0.5 5.0/5 "Blown Away!"
      I took health insurance from Hdfc ergo Am satisfied with the premium amount which am making the payment , i don't have claim experience . But this policy hold benefits of cashless hospitalization and network of hospital. Their customer explained the policy very well.
      Was this review helpful? 0
      , bangalore
      Reviewed on Sep 04, 2018
    • Apollo Munich Health Insurance
      "Normal Service"
      0.5 3.0/5 "Satisfactory"
      I have a health insurance policy with the Appollo Munich, I make the premium payments online. So far there hasn't been any claim experience with the policy. I'll have to wait and see how the respond to my claim request If I'll have any in future.
      Was this review helpful? 0
      , guntur
      Reviewed on Aug 31, 2018
    • United India Health Insurance
      "Good Service so far"
      0.5 4.0/5 "Great!"
      I've a a health insurance policy from the United India Insurance company. The company is paying premium and the entire family is covered. It offers an annual coverage of 3 Lacs. There hasn't been any claim experience so far with the policy.,..
      Was this review helpful? 0
      , chennai
      Reviewed on Aug 29, 2018
    • National Insurance Health Insurance
      "Good Policy"
      0.5 4.0/5 "Great!"
      I have a health insurance policy with National insurance from last 8 months, i am not aware of the premium amount as my company pays it. If i want additional premium then i have to pay Rs 1500. I have no claim experience from this insurance and the coverage value is Rs 3 lacs.
      Was this review helpful? 2
      , ghaziabad
      Reviewed on Aug 29, 2018
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