Health Insurance: The majority of health insurance providers are working hard to increase their healthy claim payment ratio. As a last resort, the health insurance provider may, nevertheless, reject a claim in specific circumstances. You would never want to be in the position of a policyholder where your health insurance claim is denied. Being hospitalised yourself or a family member is a stressful event, and having your claim denied just makes it worse. This post will explain the top 9 reasons health insurance claims are denied and what policyholders can do to prevent them.
Common Reasons for Health Insurance Claim Denials
These are some typical explanations for why the majority of health insurance claims are denied. We have also provided you with advice on how to prevent rejection.
Inaccurate or deceptive information
Please make sure that all of the information you enter on the health insurance application form is correct. No information should be intentionally or inadvertently misrepresented, as this could result in the denial of the claim. The details could pertain to:
- Age,
- Income,
- Existing medical insurance policies,
- Profession (specifically if you are in a hazardous occupation),
- Hobbies (specifically if you are into adventure sports like hiking or scuba diving), etc.
When determining whether to accept a health insurance application and at what premium, the health insurance company will consider all of the information listed above as relevant. Rather than asking your agent or anyone else to fill out the application, you should do it yourself. They might not have all the information needed about you to correctly complete the form.
Details concerning past medical conditions and unhealthy behaviours
Health insurance claims may be denied if information regarding one’s own pre-existing conditions, family medical history, sedentary lifestyle, and habits such as alcohol consumption and smoking is withheld. To avoid paying a higher premium or having their policy rejected, some people might choose to hide this information. You have to include information about any pre-existing conditions you may have on the health insurance application form. You should include any family history of a disease in the medical history or family history section.
If you smoke, the insurance provider might inquire about your daily cigarette consumption. If you drink alcohol, you might be asked to disclose how much and how often you drink it. The health insurance provider can more accurately price the risk thanks to the information above. The insurance provider may, if necessary, impose an exclusion or suitable waiting period before providing coverage for a particular pre-existing condition.
Reclamations for unpaid services
Every health insurance plan does not cover every service. Certain policies may contain them, but they might also have restrictions or other conditions. Should you submit a claim for any of these uncovered services, the health insurance provider will deny the claim. Among these services are the following:
- Dental treatment
- AYUSH treatment
- Out Patient Department (OPD) services
- Maternity claim
Read your policy document to see if any of the aforementioned are covered before submitting a claim. Verify the extent of coverage and the associated terms and conditions if they are covered.
Exclusions
Some procedures or treatments might be regarded as standard exclusions by all insurance providers. Meaning that they won’t be covered by most plans. Among them could be a few of these:
- Plastic surgery or cosmetic surgery
- Treatment of genders differently
- Therapy as a result of engaging in risky or adventurous sports, like gliding, rock climbing, motor racing, horse racing, scuba diving, etc.
- Therapy resulting from someone breaking the law or attempting to break the law with the intention of committing a crime
- Treatment for drug addiction, alcoholism, or any other addictive disease
- costs associated with fertility and steripty, etc.
These are a few of the exclusions that are present in the majority of health insurance plans. Check the policy wordings (Exclusions Section) for any exclusions that apply specifically to your policy.
A claim under a lapsed policy
A health insurance policy is only good for the period of time for which the premium has been paid, such as one year or several years. The policy must be renewed and the renewal premium must be paid after the predetermined period of time has passed. If you fail to pay the renewal premium within the allotted time, the policy will expire. When you file a claim under a policy that has expired, the insurance provider will deny your claim. To keep your policy active, check the date of expiration and make sure you pay the renewal premium on time or ahead of schedule. It is advised that you have your policy’s renewal premium paid by automatic debit.
The amount of the claim exceeds the amount guaranteed
There is a maximum insured amount on every health insurance policy. What happens if, in the event that you have already made claims for the same year, the claim amount exceeds the remaining sum insured? Subject to the terms and conditions of the policy, the insurance company will approve the claim up to the remaining amount insured. You should review the amount of coverage provided by your health insurance every few years, as medical inflation is on the rise. A higher coverage amount can be purchased or upgraded to keep up with medical inflation.
Not providing timely notice to the insurance provider
The insurance company may deny your claim for cashless treatment if you fail to notify them of your hospitalisation within the allotted time. You might obtain the authorization before being admitted to the hospital if it is a planned hospital stay. According to the terms of your policy, you must notify the insurance company 24 to 48 hours after being admitted to the hospital for an emergency caused by an accident or for any other reason.
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