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Insurance Article

#NotFAQs: Under What Circumstances Can My Health Claim Get Rejected?

July 24 2020
Rejected health claim

Health is wealth – this is what we've grown up learning. If you're a planner and believe in taking care of your health, you may already have invested in health insurance. Or, you may be on the lookout for the perfect health policy that covers all your concerns. But what would happen if you face a health emergency and your insurance claim gets rejected? That's not something anyone wants even to imagine. To be truly prepared for such a situation, you need to know the grounds on which health insurance claims can be denied. Let's take a look at some of the questions that may pop up in your mind.

What if some of my documents are incomplete/missing, will my claim still be processed partially? Or will it be rejected?

For cashless claims, we communicate directly with the network hospital you're treated in. So, in this case, you don't need to worry about missing out on any medical document.

For reimbursement claims (in case you're treated at a non-network hospital), two scenarios can arise:

  1. Non-mandatory documents are missing – We will still process your claim.
  2. Mandatory documents are missing - We will remind you about the missing documents every 15 days, i.e. on the 15th day, 30th day, 45th day and lastly on the 60th day. Post this final reminder; the claim will be rejected due to non-receipt of mandatory documents.

Say I uploaded all my medical documents/sent them by post, but they didn't reach the insurance company in time. Does my claim get rejected?

At ICICI Lombard, we provide a 15-day grace period for reimbursement claims. If the documents have not reached us post this grace period due to an inadvertent delay, you can contact us with the explanation for the same and resend/re-upload the documents. We will still process your claim.

Okay got it. What if I underwent treatment for a condition that's my policy doesn't cover? Can I still claim for it?

Health insurance policies have a list of exclusions that are not covered. If you've filed a claim for an ailment falling under these exclusions, then as per the policy terms and conditions this claim would not be accepted. To avoid any confusion at the time of undergoing treatment, we recommend going through the policy wordings thoroughly before purchase.

That reminds me, what if a pre-existing disease is not disclosed while buying the policy? Why does the company need details about such conditions anyway?

Utmost good faith is one of the basic principles of insurance, and all insurance contracts are built on the factor of trust between both parties. When you apply for health policy, you need to disclose the pre-existing diseases that you have, if any. It helps the insurer assess the health risk for your plan correctly. Sometimes people worry about not getting insurance due to diabetes or hypertension, and hence they don't disclose such pre-existing conditions. However, if a claim arises due to such a condition, it may be rejected due to non-disclosure.

What about lifestyle choices? For example, does a history of smoking/drinking affect my future health insurance claims?

Lifestyle choices don't directly affect your future claims. However, there are exceptions, such as, but not limited to, alcohol consumption, which impact the admissibility of the claim.

Are there any assumptions that people make with regards to claims, which end up being the cause of claim rejection?

Some of the common assumptions are related to alcohol, diabetes, hypertension, heart disorders, cancers etc. People think if they disclose a condition like this, their policy will be denied or claims will be rejected. Hence, they conceal such existing medical conditions while applying for insurance, as well as during hospitalisation. This, in turn, may mislead the treating consultant in arriving at an appropriate diagnosis.

That's not good. Okay, if I am going to be hospitalised, by when do I need to let you know?

As per your policy terms and conditions, you would have a specific deadline to inform us about the hospitalisation. If you've not intimated us or the TPA within the stipulated timeframe, your claim may be rejected. Typically you need to inform us 2-3 days in advance about planned hospitalisations. In case of emergency hospitalisation, intimate us or the TPA within 24 hours.

If I have just bought the policy and need to be hospitalised, can I make a claim?

There is a 30-day initial waiting period on most health policies, except accident-related claims. The waiting period is 15 days for COVID-19 claims. There is also a separate waiting period of specified duration like 1 year, 2 years or 3 years as per the customisation of your policy. Most of the elective surgeries like cataract, kidney stones, gall bladder stones, joint replacements, maternity-related etc. fall under this condition. Read your policy documents thoroughly to know more.

What if my policy has expired? Can I claim during the grace period that you provide for renewal?

If you miss the insurance renewal date and end up filing a claim on the expired policy, your claim would be rejected. Renewing the policy in time is crucial to ensuring you don't miss out on a claim during a medical emergency. Although there is a 15-day grace period for renewals, insurance companies usually don't service your claim during this period. So it's best to renew in advance and stay protected against any unexpected health concerns that need immediate treatment.

I have already made a couple of claims in the year. What if my sum insured is exhausted and I want to make another claim during the policy year?

If you've already made a few claims in the policy year and your sum insured (the maximum amount available in the year as per your policy) is used up, then your subsequent claims may be denied. Opting for a higher sum insured is a better idea, especially if you're buying a single policy for the whole family. ICICI Lombard Complete Health Insurance also comes with a reset benefit, whereby we rest up to 100% of the sum insured within the same policy year, in case the sum insured is inadequate due to previous claims and the claim is for a new diagnosis. The reset benefit doesn't apply for the first claim of policy year.

I prefer Ayurvedic treatment. What do I need to know to ensure my AYUSH claim is not rejected?

Most insurance companies, including ICICI Lombard, will not cover hospitalisation expenses for evaluation or investigation only. Also, treatment taken at a healthcare facility which is not a hospital is not covered. When you're planning to undergo AYUSH treatment, be sure to choose a Government Hospital or any institute recognised by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health.

Apart from the reasons we've covered, there may be other causes for claim rejection too. To avoid the pain of a denied claim, we recommend reading the policy documents thoroughly so that you're aware of all the terms and conditions. These documents clearly outline the inclusions, exclusions and deductibles of the policy. Moreover, you must keep yourself informed about the claim process and have the contact numbers of your insurer/TPA handy for assistance. ICICI Lombard has a simple, app-based claim process to make your experience hassle-free. You can intimate us for a claim, submit your documents, and check your claim status easily on our IL Take Care app. If you're interested in insuring your health with us, take a look at our health insurance plans.

What to do in case of a claim rejection:

If you've filed a claim and your insurer rejects it, you can still try to find a solution. Go through your policy documents again and understand the reasons behind the claim rejection. Here are some steps you can take -

  • In case your claim was rejected due to missing information, contact us or the TPA and share the pending details. Maintain a record of all your interactions with the insurer for future reference.
  • If your claim was rejected due to unfiled documents, submit all the pending documents within the specified timeframe. If you filed the claim with the help of your TPA, take their assistance to submit the missing documents again.
  • Sometimes a claim may be rejected if the treatment was medically unnecessary. In this case, you can share the accurate medical details by providing a supporting letter from your doctor, an expert opinion or even medical research. You can file an appeal for the denial of your health insurance claim in this case.

After taking the above steps, if your claim is still denied and you're not satisfied with the reason, you may provide a written complaint to the Ombudsman. You need to do this within 30 days of receiving a response from the insurance company.

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