You need health cover regardless of what you take two at a time - pills or stairs.

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 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

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  • Bajaj Allianz Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I took my Health insurance with Bajaj allianz general insurance, they have tie up with many hospital, and they have shared me location regarding this, so far there was no claim experience with them . There is cashless treatment option available , the premium amount they have charged me previously on monthly basis, it was nominal premium charges, i have been paid for 4-5 years continuously, now maturity period got completed.
    Was this review helpful? 0
    , new delhi
    Reviewed on Jan 22, 2019
  • HDFC Ergo Health Insurance
    "Not satisfied with the service"
    0.5 1.0/5 "Really Bad"
    It was not quite a good experience i had with them where i had started this insurance policy in the year of 2009 and i had been paying the premium amount of 50,000 annually. There was not any single claim which i had made so far, until last year i had tried for a claim and the bill was around 40,000 and they had provided me with only 12,000 which was really a bad experience.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 21, 2019
  • HDFC Ergo Health Insurance
    "Its Good"
    0.5 1.0/5 "Really Bad"
    Before four month my health policy got expired I don't have interest to renew it again. HDFC Ergo representative called me for the renewal. I don't have claim experience but I believe they provide ac room hospitalization for per day Rs. 3000 will be charged from the insured value and they do have no bonus feature.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 21, 2019
  • Star Health Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I have been using my health insurance with Star health insurance, there service is good,i have applied two health loan , one for me and one for my parents, i had claim experience with it , as one year ago,i avail this insurance for my parents, there was cashless option available , and the premium amount they have charged me was nominal, for my parents i use to pay up to 27,000 as yearly basis, and for me 12,000 as yearly basis.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 21, 2019
  • HDFC Ergo Health Insurance
    "Excellent service"
    0.5 5.0/5 "Blown Away!"
    I have been using my health insurance with HDFC ERGO , the agent that explain me clearly about the policy, and there benefits,and they have tie up with many hospital and they have shared me excel regarding this, i had claim experience on 2016 , my claim experience with this bank was good, the premium amount they have been charged on yearly basis,they have charged premium nominal.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 21, 2019
  • Universal Sompo Health Insurance
    "Speedy claim recovery"
    0.5 4.0/5 "Great!"
    Holding my health insurance from Universal sompo. I'm not getting any mails or messages from Universal Sompo regarding the updates. The policy is really good. This is a 100% covered policy. They have processed the claim immediately with the cashless treatment. The hospital list is really good.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 20, 2019
  • HDFC Ergo Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I took my medi claim with HDFC ERGO, they have tie up with many hospital,and they have shared me the location regarding this,they have mention the location on excel,and the premium amount they have charged me is nominal,they have charged me on yearly basis.overall service is good.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • HDFC Ergo Health Insurance
    "Average Policy"
    0.5 3.0/5 "Satisfactory"
    I have purchased the health insurance from HDFC Ergo. For some enquiry, i have called the customer care service and they have resolved my query immediately. I have not made any claim experience so far. I pay the premium amount of Rs. 37000 and myself has been covered in this policy.
    Was this review helpful? 0
    , gurgaon
    Reviewed on Jan 20, 2019
  • Reliance General Health Insurance
    "Overall Experience is good"
    0.5 4.0/5 "Great!"
    I'm using the health insurance from Reliance last 5 years. Since I'm the in charge of corporate insurance the customer care service is really fine. I made many claim from Reliance for other employee. As per the policy, they are fulfilling the customer needs. They are providing good cashless treatment facility. They used to send a updation on a regular basis.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • Apollo Munich Health Insurance
    "Very Good Policy"
    0.5 5.0/5 "Blown Away!"
    I have a corporate covered health insurance policy from Apollo Munich. They have given me a coverage value of Rs. 4 lakhs. My entire family has been covered in this policy. This policy covers all the major hospitals in all over India. I have not made any claim so far.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Jan 20, 2019
  • ICICI Lombard Health Insurance
    "Average Policy"
    0.5 3.0/5 "Satisfactory"
    My health insurance was purchased from ICICI Lombard. To apply the claim, its a lengthy process. I had a claim experience and they have given the claim upto 80%. I pay the premium amount of Rs. 12500 every year. My entire family has been covered in this policy.
    Was this review helpful? 0
    , indore
    Reviewed on Jan 20, 2019
  • HDFC Ergo Health Insurance
    "Excellent service"
    0.5 5.0/5 "Blown Away!"
    I experience my health insurance with HDFC Ergo,they have tie up many hospital ,i have not have claim experience yet,there is cashless treatment option available,the premium they have charged me on monthly basis,they have charged me up to 700 which is nominal , i pay premium through on line.
    Was this review helpful? 0
    , kolkata
    Reviewed on Jan 20, 2019
  • Star Health Health Insurance
    "Excellent service"
    0.5 5.0/5 "Blown Away!"
    I have been using health insurance with Star health insurance, the agent had clearly explain me amount the claim policy, and they have tie up with my hospital, and they have charged me location regarding to hospital location, there premium amount is on yearly basis, and it use to get auto debited from my account.
    Was this review helpful? 0
    , thane
    Reviewed on Jan 19, 2019
  • HDFC Ergo Health Insurance
    "Best Policy"
    0.5 5.0/5 "Blown Away!"
    I have taken Health insurance from Hdfc ergo insurance . Am satisfied with the premium amount which am making the payment for every 2 years . This policy gives good coverage with cashless hospitalization and pre disease cover . Even they have given network list of hospitals . While taking the policy they have explained very well about policy and claim .
    Was this review helpful? 0
    , bhubaneshwar
    Reviewed on Jan 19, 2019
  • United India Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I have been using my mediclaim insurance with United state of India,the premium i use to pay on yearly basis,i need to pay through on line,they have tie up with many hospital , i no doing much important is that they have share the location,i have no claim experience yet,till now no issue ,any changes they use to notify and use to send hard copy.
    Was this review helpful? 0
    , bangalore
    Reviewed on Jan 19, 2019
  • Star Health Health Insurance
    "Good service"
    0.5 4.0/5 "Great!"
    I have my health insurance with Star health insurance, i had claim experience with it, my experience was good, they have good tie up with my hospital and they have mailed me about the location of it, and i am happy with there service, they have charged me premium amount on yearly basis, and the premium amount is nominal for me, and i use to pay through on line mode.
    Was this review helpful? 2
    , chennai
    Reviewed on Jan 17, 2019
  • HDFC Ergo Health Insurance
    "Very good benefits"
    0.5 5.0/5 "Blown Away!"
    I have a health insurance from HDFC ERGO which was purchased by me in the year of 2018 because the benefits are very good. The claim process was simple and they have more number of hospitals for cashless. I have paid 18,800 for one year and took 3 years policy for myself and my wife. The medical coverage is 10L for myself and 5L for wife.
    Was this review helpful? 2
    , bangalore
    Reviewed on Jan 14, 2019
  • ICICI Lombard Health Insurance
    "Good Health insurance provider"
    0.5 3.5/5 "Pretty good"
    This policy was part of my employment, I took the medical coverage of Rs. 5 lakhs for the tenure of one year, this medical benefits for my entire. They have good networks of hospital with major disease cover. But I think it doesn't have no claim bonus.
    Was this review helpful? 0
    , chennai
    Reviewed on Jan 11, 2019
  • Reliance General Health Insurance
    "On time approval with reliance"
    0.5 4.0/5 "Great!"
    For my spouse operation I used the health policy, I approached them for the claim through hospital. I submitted the form and they send the papers to the Reliance insurance company. I got the cash less treatment, but I paid some amount which was not covered. But they gave me the on time approval.
    Was this review helpful? 1
    , kolkata
    Reviewed on Jan 11, 2019
  • Cigna TTK Health Insurance
    "On time service"
    0.5 5.0/5 "Blown Away!"
    On time Cigna TTK have activated the policy which provided by the company, the policy which I hold it has the coverage of Rs. 4 lakhs its covers for me. They are providing coverage for the pre existing with the tax benefits but there is no claim.
    Was this review helpful? 1
    , dandeli
    Reviewed on Jan 10, 2019
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