How to Deal with a Health Insurance Claim Rejection?

When your health insurance claim gets rejected, you should look for errors in the claim form you submitted. You can get your claim form rectified with the support of a third-party representative (TPA) with accurate documents.

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 .
  • 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.
Health Insurance Related Pages

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.

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