Health insurance: Tips to ensure your health claim is not rejected

A lot of the medical insurance insurance policies have a ready or cooling interval clause for sure pre-existing illnesses or maternity. Additional, the insurance policies have an exhaustive listing of exclusions that aren’t lined.

Rejection of insurance coverage claims is frequent, particularly in medical insurance. Allow us to talk about the frequent causes for which insurance coverage corporations reject claims, tips on how to keep away from the identical and cures out there to the policyholder in case of rejection of medical insurance claims.

False data
The commonest floor for rejection is offering incorrect or false data within the software type. It’s important to supply right data, particularly knowledge equivalent to age, earnings, occupation and most significantly, life-style habits equivalent to smoking, consuming, moreover data on different insurance policies and claims. Offering incorrect data is deemed as fraud as a result of the premium quantity is decided in line with the data offered within the software.

Non-disclosure of pre-existing illness
It is vitally vital to reveal any of the pre-existing illnesses equivalent to cardiovascular ailment, blood stress, surgical procedures undergone, some other hereditary circumstances, and many others., since a number of the pre-existing illnesses are usually not lined and protection / declare might in all probability be denied in occasions of hospitalisation as a result of pre-existing illnesses.

Ready / cooling interval
A lot of the medical insurance insurance policies have a ready or cooling interval clause for sure pre-existing illnesses or maternity. Additional, the insurance policies have an exhaustive listing of exclusions that aren’t lined. So, any declare produced from the exclusion listing won’t be thought-about by the insurance coverage corporations.

Exceeding time restrict for declare
It can be crucial for the insured to use / intimate for reimbursement inside a sure time frame.

As for emergency admission, the time given is 24 hours after the affected person has been admitted, and in different circumstances, it will possibly change in line with the kind of coverage one opted for and the therapy being availed by the insured. If the policyholder didn’t apply /intimate inside the time specified, then the declare could be rejected.

Learn how to keep away from rejections?
One ought to perceive that insurance coverage is mainly a contract drawn upon good religion, so it can be crucial for the coverage holders to supply full, right, correct and most up-to-date data associated to each medical and non-medical (monetary data) on the time of making use of for an insurance coverage coverage to keep away from declare rejections later. It’s all the time advisable to refill your correct declare types by means of your insurance coverage firm’s Third-Occasion Directors (TPA).

Enchantment mechanism
There are elaborate and established procedures inside insurance coverage corporations earlier than rejecting or repudiating claims. As a primary step, when the clam is rejected, the insured ought to strategy the service high quality staff of the insurance coverage firm for escalation. It is vitally vital to grasp the explanations for rejection. Policyholders can ask the insurance coverage firm in writing to evaluate their resolution to disclaim the declare. The Insurance coverage Regulatory Improvement Authority of India (IRDAI) has set a time restrict of 15 days for insurance coverage corporations to resolve the problem.

If the insurance coverage firm fails to handle the problem inside the above time window or the insured is just not pleased with the decision, then the policyholder can file a grievance by means of Irdai’s built-in grievance administration system.
If the insurance coverage firm refuses to settle the declare after the regulator’s intervention, then the coverage holder can strategy the insurance coverage ombudsman for grievance redressal.

To conclude, one can simply keep away from declare rejection by avoiding the frequent errors as mentioned above.

The author is a professor of finance & accounting, IIM Tiruchirappalli

Causes to reject
Incorrect data is deemed as fraud as a result of the premium quantity is decided in line with the data offered within the software.
Declare or protection could be denied in occasions of hospitalisation attributable to pre-existing illnesses or claims made inside ready interval.
If the policyholder doesn’t apply /intimate inside the time specified, then the declare could be rejected.