Steps To Avoid A Health Insurance Claim Rejection

One of the most important steps to take when planning your finances for the future is to make sure that you are insured. Be it a life insurance policy, health insurance policy or a motor insurance policy, the policyholder and his/her dependents are financially protected following an unforeseen event such as an accident, death, illness, or disability. With regard to health insurance, the policy ensures that the expenses for hospitalisation, surgeries, or treatments are covered up to the sum assured of the policy that one holds. This reduces the out-of-pocket expense of the policyholder and ensures that he/she is not financially set back if he/she is hospitalised or has to receive treatment.

However, quite often health insurance policyholders assume that just by paying the premium of the health insurance policy, the insurer will cover the expenses come what may. This is a false notion, as insurers have every right to not offer coverage for the medical expenses, irrespective of whether the policy is valid, and most often, their reason to reject a health insurance claim boils down to the mistake of the policyholder. Following a claim for medical coverage by the policyholder, the insurer assess whether the policyholder is eligible to receive coverage and the factors that lead to the policyholder raising the claim. That said, in order to help policyholders avoid claim rejections, we’ve listed out a few instances when insurers will reject claims and the reasons behind the rejection of the claim.

Reasons for Health Insurance Claim Rejections:

Some of the common reasons why health insurers reject claims are listed below:

  • Incorrect facts or non-disclosure of facts

If the policyholder submits wrong information at the time of the issuance of the policy, such as wrong credentials, if he/she suffers from a pre-existing disease or is a smoker, then the insurer has every right to reject the claim. In addition, giving wrong information with regard to illness or disease, or what leads to the hospitalisation of the insured person, is another reason why insurers will reject the claim.

  • If the disease or treatment is under the exclusion list

If the policyholder raises a claim for coverage of medical expenses, and if the treatment or disease is listed under the exclusion list of the policy, then the insurer will reject the claim. In addition, if hospitalisation or illness is caused as a consequence of any of the conditions listed in the exclusion list, then the claim will be rejected. For example, if the insured person meets with an accident because he/she was intoxicated, if the insured person tried to commit suicide, etc.

  • If the policy has lapsed

If the policyholder raises a claim and the policy has lapsed, then the claim will be rejected by the insurer without thinking twice. Following the expiry of the policy, the policyholder is given a grace period to pay the premiums. If he/she fails to pay the premiums during the grace period, then the policy will lapse.

  • If the policyholder has not disclosed information about his/her existing policy

If the policyholder is applying for a fresh health insurance policy and does not disclose facts about his/her current policy, then the insurer has every right to reject the claim of the policyholder.

  • If the policy is still in the waiting period

For a lot of policies, the policyholder will have to serve a waiting period before he/she can raise a claim. In addition, the treatment for certain diseases and critical illnesses comes with a waiting period. If the policyholder raises a claim during the waiting period, then the claim will be rejected.

What to Keep in Mind to Avoid a Health Insurance Claim Rejection:

Policyholders have to keep in mind the below-listed points to avoid a claim rejection:

  • Ensure that you fill the form

Most often, policyholders leave the filling of the form to the insurance agent, and in the process, some details mentioned on the policy issuance document might be wrong. The credentials and other personal details of the policyholder have to match other government approved documents, if not, this might come to the notice of the insurer at the time of the claim and the insurer will reject the claim.

  • Be honest when disclosing facts

One of the main reasons why claims are rejected is because the policyholder hides information to get a better premium rate. Not disclosing facts such as whether you are a smoker, if you suffer from pre-existing diseases and other relevant information will result in the insurer rejecting the claim. In addition, the insurer has every right to even terminate the policy if the policyholder has failed to disclose facts.

  • Read the fine print of the policy document

As clearly mentioned, policyholders often assume that just by paying the premium of the policy, the insurer is entitled to cover all hospitalisation and treatment expenses up to the sum assured of the policy. However, the insurer will extend coverage for hospitalisation only if the treatment or hospitalisation does not fall into the exclusion category. If the treatment or reason for hospitalisation is under the exclusion list, then no coverage will be extended.

  • Getting unnecessary treatments or tests

Since they have a health insurance policy, policyholders often assume that the insurer will cover all the costs. This could lead to the policyholder taking unnecessary tests which will very well be supported by the hospital. However, with regards to tests and treatments, there are certain policy terms and conditions that the policyholder might not be aware of.

  • Check which treatments and diseases the policy covers

When buying the health insurance policy, the policyholder has to go through the policy document thoroughly and see what sort of treatments, surgeries, diseases, and illnesses the policy will cover. If the disease or illness is not covered by the policy, then the claim for coverage of medical expenses will be rejected immediately.

  • Know the listed hospitals

Every health insurer has a list of hospitals that they work with to offer their policyholder the benefit of the cashless facility. Prior to admission, ensure that the hospital is listed by the insurer else you will have to settle for a reimbursement claim.

All in all, when buying a policy, the policy applicant has to take the responsibility of going through all the policy terms and conditions, the extent of coverage, what will be covered by the policy, and the listed hospitals. When raising a claim, the policyholder has to be 100% sure that he/she is eligible to receive the coverage and by being confident, he/she can take the the insurer to task if by chance the claim is rejected.

 4.5 / 5.0   by 6543 users
Used this product? Write a review >>

Cashless Treatment

Policy Coverage

Customer Service

Medical Coverage

Claim Experience

Display of any trademarks, tradenames, logos and other subject matters of intellectual property belong to their respective intellectual property owners. Display of such IP along with the related product information does not imply BankBazaar's partnership with the owner of the Intellectual Property or issuer/manufacturer of such products.

Steps To Avoid A Health Insurance Claim Rejection Reviews

Page 1 of 50 1 2 3 4 5
  • Star Health Health Insurance
    "Good policy "
    0.5 3.0/5 "Satisfactory"
    I taken a health insurance from STAR HEALTH on last 6 months back which was taken via online. It covers my whole family of 3 members for the total amount of 5. The premium amount need to pay of 12K. The tenure period of 1 year. I have not used this card much. I haven't done any claim yet.
    Was this review helpful? 1
    , bangalore
    Reviewed on Mar 20, 2020
  • Bajaj Allianz
    Bajaj Allianz Health Insurance
    "Good policy "
    0.5 4.0/5 "Great!"
    I have taken a health insurance policy from Bajaj Allianz which was taken for my mother. Policy coverage value was Rs. 1L and the premium its a one time payment, i got a offer because i am maintain CREDIT SCORE good. Still there is a no claim and i paid 3 years back, during renewal time i am not getting any calls from insurance company. This policy covers 200 hospital 30-50% in all hospital can get a claim.
    Was this review helpful? 0
    , bangalore
    Reviewed on Mar 20, 2020
  • Religare Health Insurance
    "Good insurance company "
    0.5 5.0/5 "Blown Away!"
    My personal need I taken health insurance from RELIGARE on 2 years back. Actually my previous company taken health insurance got lapse, hence for better option I continued with same need to pay the premium of 5K. It covers up to myself. The coverage amount of 5L, since there is no claim yet I got bonus of 10% so as of now 5.5L. They tied up with many hospitals and cash less treatment is applicable.
    Was this review helpful? 1
    , bangalore
    Reviewed on Mar 19, 2020
  • Max Bupa Health Insurance
    "Good policy"
    0.5 4.0/5 "Great!"
    This is an individual policy, cover fro myself and this is from Max Bupa. Yearly i am paying premium of Rs. 3000 and the coverage value of Rs. 5L and still there is a no claim. Every year i am getting 5% no claim bonus and this is a life long policy. Its a tax benefit plan for major and listed hospitals can avail a cash less, if non listed have to pay then we can reimburse.
    Was this review helpful? 0
    , chennai
    Reviewed on Mar 19, 2020
  • Royal Sundaram Health Insurance
    "Good insurer"
    0.5 4.0/5 "Great!"
    My employer has given me a health insurance policy from ROYAL SUNDARAM and they have provided me a coverage amount of Rs. 3L. It covers myself and my spouse are covered in this policy.The premium amount need to pay of 7.5K on yearly basis. They have a cashless facility with many hospital.
    Was this review helpful? 0
    , chennai
    Reviewed on Mar 19, 2020
  • Star Health Health Insurance
    "Excellent service"
    0.5 5.0/5 "Blown Away!"
    I have taken health insurance from STAR HEALTH on last year for my personal use, it covers my whole family of 4 members. The sum average value is 5L. I am renewing the policy by paying the premium amount of 14K on yearly. Many hospitals are tied with them and they provide cashless treatment as well.
    Was this review helpful? 0
    , rajahmundry
    Reviewed on Mar 18, 2020
  • Star Health Health Insurance
    "Average "
    0.5 3.0/5 "Satisfactory"
    For my personal purpose, I have taken a health insurance from TATA AIG on 3 years back. On yearly, I use to renew the policy which I need to pay the premium amount of 20K via online. It covers up to myself. The sum assured amount is 2.4L. They tied up with limited hospitals only and there is no cashless treatment.
    Was this review helpful? 0
    , bangalore
    Reviewed on Mar 18, 2020
  • Oriental Insurance Health Insurance
    "Good policy "
    0.5 5.0/5 "Blown Away!"
    My company provides me a health policy from ORIENTAL insurance and this is a group insurance. Annual premium i am paying Rs. 4840 and still there is no claim and the coverage value is Rs. 2 lakhs. During the renewal time, i use to get reminder call from the support team.
    Was this review helpful? 1
    , kolkata
    Reviewed on Mar 16, 2020
  • review Health Insurance
    "Need online service "
    0.5 5.0/5 "Blown Away!"
    I am paying about Rs. 20k yearly for health insurance to PARAMOUNT. This is group policy and the coverage of Rs. 10L since 5 years i am using this health insurance. I went for a claim which was reimbursed. The main factor is they are asking lots of documents which they need to make it simple.
    Was this review helpful? 0
    , thane
    Reviewed on Mar 15, 2020
  • Bajaj Allianz Health Insurance
    "Okay"
    0.5 4.0/5 "Great!"
    I have received the Bajaj Allianz mediclaim policy from Bajaj Finserv on EMI basis. Cashless facility is available and am paying Rs.640 for a month. This policy is not available in the market. I wish if their executive were more polite and helpful. Its a self policy which covers 5L. Am renewing this policy from last 3years.
    Was this review helpful? 1
    , kochi
    Reviewed on Mar 15, 2020
  • Star Health Health Insurance
    "Good "
    0.5 5.0/5 "Blown Away!"
    Health insurance policy which i have taken from STAR HEALTH and this is a family floater policy. I am using since 4 years still there is no claim and this insurance will cover all types of critical illness. Annually i am paying premium Rs. 13000 and its a Tax benefit policy.
    Was this review helpful? 1
    , bangalore
    Reviewed on Mar 14, 2020
  • ICICI Lombard Health Insurance
    "Good policy"
    0.5 4.0/5 "Great!"
    ICICI offered me a health insurance and this is a group policy which covered for Rs. 4L. This insurance will cover all types of critical illness and day care treatment, still there is no claim with ICICI Lombard. I can avail cashless treatment with the listed hospitals.
    Was this review helpful? 1
    , hyderabad
    Reviewed on Mar 14, 2020
  • United India Health Insurance
    "Best policy "
    0.5 5.0/5 "Blown Away!"
    From United India Insurance, i have taken a health insurance. This is a group insurance and i am paying premium per annum Rs. 4900. This policy covers all critical illness and there is a no age criteria, I can use this policy for life long. It covers Tax benefit under sec 80D also network of hospitals are good.
    Was this review helpful? 0
    , kolkata
    Reviewed on Mar 13, 2020
  • United India Health Insurance
    "Good"
    0.5 4.0/5 "Great!"
    This is a group health policy which was taken through TATA AIG and the coverage value of Rs. 3L. I am paying premium yearly Rs. 6000. Its been one year and still there is no claim and this policy covers day care treatment and this can be used till life long.
    Was this review helpful? 0
    , bangalore
    Reviewed on Mar 13, 2020
  • Apollo Munich Health Insurance
    "OKAY"
    0.5 5.0/5 "Blown Away!"
    From Apollo Munich, i have taken a health insurance and this is a joint policy. The policy coverage value is Rs. 5L for a life long. I am paying the premium yearly Rs. 16k and still there is no claim on this policy. It covers all network of hospitals.
    Was this review helpful? 0
    , indore
    Reviewed on Mar 13, 2020
  • Star Health Health Insurance
    "WORST and WORST"
    0.5 0.5/5 "Unacceptable"
    Star health and Allied insurance cheaters don't go with this policy they are looting people worst and worst there are corporate beggars- frauds ,corporate beggars- frauds ,corporate beggars- frauds ,corporate beggars- frauds ,corporate beggars- frauds
    Was this review helpful? 0
    , bangalore
    Reviewed on Mar 12, 2020
  • Star Health Health Insurance
    "Nice Policy"
    0.5 4.0/5 "Great!"
    From my company side, they have provided me a health insurance from TATA AIG. I can do a cashless treatment facility in a network hospital hence i have fixed the appointment also. This policy covers only for myself. They have given me a coverage value of Rs. 3 lakhs. I don't have any claim experience till now.
    Was this review helpful? 0
    , chennai
    Reviewed on Mar 12, 2020
  • Star Health Health Insurance
    "Good products at affordable right pricing"
    0.5 4.0/5 "Great!"
    I love the way they communicate everything. Inclusions and exclusions were explained in a right way to help me choose right product at right pricing. i got a healthcare for my whole family without burning a hole in my pocket. recommended to all
    Was this review helpful? 0
    , mumbai
    Reviewed on Mar 11, 2020
  • Star Health Health Insurance
    "Good "
    0.5 4.0/5 "Great!"
    My friend has suggested to apply health insurance, so for my personal need I had taken a health insurance from STAR HEALTH on 10 months before. They tied up with many hospitals and it covers all city. There is cash less treatment and the policy includes 4 family members, need to pay the premium amount of 12K on yearly basis.
    Was this review helpful? 1
    , chennai
    Reviewed on Mar 10, 2020
  • review Health Insurance
    "Good"
    0.5 5.0/5 "Blown Away!"
    My health insurance policy is running with Aditya Birla Health Insurance. This is a family floater policy and i am paying premium around Rs. 14k yearly. Still there is no claim and this insurance covers all network of hospitals. This policy has some TAX benefits.
    Was this review helpful? 0
    , lucknow
    Reviewed on Mar 09, 2020
Common Loader Icon
Page 1 of 50 1 2 3 4 5
reTH65gcmBgCJ7k
This Page is BLOCKED as it is using Iframes.