• En
  • En

Every health insurance company makes its own plans; these plans can be quite confusing and difficult to understand. Most people who buy a health insurance policy are not too interested in knowing all the details of the plan. All they enquire about is the amount the insurance company can give as medical coverage. However, this does not provide a complete picture as insurance companies may not provide coverage on every medical bill or for every condition. There are many medical problems that are on the exclusions list of the health insurance plan, which means that the insurer will not provide coverage for the expenses incurred on them.

Sometimes, the situation may become even worse, like when you are not able to get a claim for the medical problems that are covered in your health insurance plan. In this article, we are going to share all the situations in which the insurer can reject your claim request and why it happens.

(Read more: Can I claim health insurance cover from two different companies?)

  1. Reasons for cancellation of claim request in health insurance
  2. What to do if the company rejects health insurance claim request
  3. Preventing claim rejection in health insurance

Most people feel financially secure after buying a health insurance policy. However, there are times when you may have a medical emergency and the company refuses to approve your claim. If this happens, the situation can become extremely troublesome for you. Therefore, it is important for you to know about the situations in which the insurer can deny you a claim:

(Read more: No Claim Bonus in Health Insurance)

  • Waiting period: Most of the insurers offer a waiting period in the beginning while offering health insurance plans, in which coverage is not given on any medical emergency for a certain period of time. For example, if you have recently purchased a health insurance plan and you are currently in the waiting period, any claim request filed by you during this time will be rejected. However, the company cannot refuse to pay the claim in case of an accident.
  • Co-payment: This is some percentage of the claim amount that you have to pay at the hospital, after which the insurer pays the rest of the amount. The co-payment percentage may be higher depending on your age. If you do not make the co-payment, your claim request may be rejected.
  • Apart from this, there are some other situations due to which the company may refuse to pay the claim amount, such as sub-limits, not giving sufficient information to the insurer, missing documents, pre-existing diseases and the insurer not notifying the company in time. Many times we are not aware of these situations, so it is important to read and understand all its documents thoroughly before buying any health insurance policy.

(Read more: myUpchar Bima Plus)

myUpchar doctors after many years of research have created myUpchar Ayurveda Urjas Capsule by using 100% original and pure herbs of Ayurveda. This ayurvedic medicine has been recommended by our doctors to lakhs of people for sex problems with good results.

Once the claim request is rejected, what should be done? Although every insurance company assures to help its customer financially as much as possible, claims can still get rejected in bad situations. Following are a few things you can do if your claim gets rejected by your insurance company:

  • Get help from the TPA: If the claim rejection is due to not filling the form properly, then you can take the help of the third-party administrator or TPA to get the form rectified.
  • Contact the hospital: If your claim request is not accepted and, you can talk to the hospital and ask for a special letter confirming that you need the treatment by the doctor. You can share this letter with the insurance company then. However, make sure that the same information is entered in the letter as you entered in your claim request form. Keep a copy of that letter with you as well. (Read more: Free-look period in health insurance)
  • Appeal claim: If the insurer rejects the claim request without assigning any reason, you can appeal for acceptance of the claim. If the company refuses to change its decision, you still have the right to appeal. The Affordable Care Act (ACA) gives you the right to appeal. If they still do not accept your claim, then you can file an Independent External Appeal. If you need medical coverage in case of a serious medical emergency, you can also request a review of the appeal as soon as possible.
  • Contact lawyer: If you have gone through all the options, even after which the insurance company is refusing to pay the claim, then you can talk to a lawyer. The attorney will review the situation and prepare the appropriate next step for you and will talk to the insurance company on your behalf. Lawyers take over the responsibility from you and legally put everything in front of the company to review. 

Obviously, even a small mistake on your part can cause you a huge loss during a medical emergency. A medical emergency is such a time, in which even a slight financial loss can be life-threatening for the patient. Hence, you are advised to fill all the forms with the correct information while filing a claim.

(Read more: Critical illness insurance)

In case of a medical emergency, not getting financial help from the insurance company can create a worrying situation. However, if you have enough knowledge and do all the document work carefully, then the risk of situations like claim rejection is reduced by a lot. Apart from this, there are some other things you can do to reduce the possibility of claim rejection in the future:

(Read more: Network and non-network hospitals)

  • Keep at least three copies of all the documents related to health insurance, so that you do not face any problem in case of loss of papers.
  • The insured should send all the papers and other records related to the medical emergency to the TPA.
  • Go through the insurance policy papers carefully before signing them, so that you are aware of any kind of exclusions, deductibles and claim processes.
  • If there is no emergency, ensure that you get the pre-authorization done by submitting a claim request to the insurer at least two days before the date of hospitalization.
  • Before submitting the claim form, read it carefully so that no part of it is left incomplete. Keep more than one form with you, so that if any mistake is made while filling the form, you can use another copy.
  • After being admitted to the hospital, keep all the papers you get from the hospital like doctor's prescription, medicine bills and test reports. If there is a claim rejection, they may be needed again.

It is clear from the above article that you may face a lot of trouble after the claim request is rejected. Given the circumstances, you are advised to know about both the company and the plan thoroughly before buying any health insurance plan. myUpchar Bima Plus is a special health insurance plan, which has been designed keeping in mind the rising number of diseases and rate of inflation. myUpchar Bima Plus also covers pre and post hospitalization medical expenses of the patient. Not only this but you are also given coverage on expenses like ambulance, ICU and room rent capping. You also get 24x7 Tele-OPD coverage in it.

(Read more: myUpchar Bima Plus for senior citizens)

Read on app
Ask your health query from live doctors now!