Health insurance plays an important role in safeguarding finances during medical emergencies. However, while having a health insurance policy is important, it is equally important to understand the claims process and be aware of the common reasons claims may be rejected.
If you hold a family floater plan or an individual health insurance policy, knowing the common reasons for claim rejections can help you avoid unnecessary stress during difficult times.
Can health insurance claims get rejected?
Yes, health insurance claims can be rejected in India. While most insurance companies strive to honour valid claims, there are instances when a claim may be denied. Rejections may occur due to incomplete information, policy exclusions or violation of terms and conditions.
This applies to almost all types of health insurance policy, including individual health insurance and group or family policies. An individual policy offers more personalised benefits, but it requires the policyholder to pay close attention to the fine print and fulfil all requirements accurately.
Common reasons for health insurance claim rejection
Here are some of the most common causes:
Waiting period is the most common reason for health insurance claim rejections. Waiting period can be of different types depending on the insurer and policy.
It is probably one of the leading causes for claim rejections. The insurance policy is based on the details that the insured provides at the time of filling the proposal form. If any discrepancy is found or if an ailment is discovered, which was not informed to the insurer earlier, then the claim will be rejected.
Every insurance policy has certain permanent exclusions that will not be covered under any circumstances. These can be anything from certain diseases to treatments. Not all policies have the same content in their exclusion list. Therefore, it is advisable to go through the exclusions carefully to avoid unexpected surprises later on.
It is important to keep a track of your premium payment due date. Paying premium on time is necessary for availing insurance cover. The policy lapses, if the premium is not paid by the due date. Claims filed under a lapsed policy will immediately be rejected, as a lapsed policy is similar to not having a policy at all.
When an emergency strikes, even the most composed people lose their wits. At that time, procedures and policies are the last things on a person’s mind. However, insurance policies require the insured to file a claim within 24 hours of hospitalisation. Failure to do so results in the rejection of the claim.
Tips to avoid rejection of health insurance claims
Here are some practical tips:
- Disclose all health details honestly
While buying individual health insurance or any policy, reveal all health conditions honestly. It’s better to pay a slightly higher premium than face a rejected claim later.
- Read the policy document carefully
Understand inclusions, exclusions, waiting periods and coverage limits. Knowing what is covered prevents surprises at the time of claim.
- Choose network hospitals for cashless claims
Before hospitalisation, check whether the hospital is part of your insurer’s network. This simplifies the process and avoids complications.
- Inform the insurer on time
For planned hospitalisations, inform the insurer at least 48 hours in advance. In emergencies, notify within 24 hours.
Keep a copy of all medical documents, prescriptions and bills. Submit them as required without delay.
- Renew policies without break
Always renew your policy on time to maintain continuity benefits, especially for pre-existing diseases.
What to do if your health insurance claims get rejected?
If your claim is rejected, don’t panic. Here are the steps to follow:
Carefully read the rejection letter or email. Insurers are required to state the reason for denial clearly.
Review your policy document and see if the rejection reason is valid under the terms you agreed to.
Reach out to the insurance company’s customer care for clarification or to address misunderstandings.
If you believe your claim is wrongly rejected, file an appeal with the insurer. Submit additional documents if needed and explain your case clearly.
What to do if your insurance company denies your claim in India?
If your insurer maintains its decision after your appeal, you can escalate the matter further:
- Approach the insurance ombudsman
The Insurance Regulatory and Development Authority of India, or IRDAI, has set up an Ombudsman system to resolve disputes. You may file a complaint online or offline within one year of the rejection.
- File a complaint with IRDAI
If unsatisfied with the Ombudsman’s decision, file a grievance through the IRDAI Grievance Redressal Portal (IGMS).
FAQs
- Can I claim for pre-existing conditions under individual health insurance?
Yes, but only after the specified waiting period, which varies by insurer.
- How long does it take to process a health insurance claim?
Cashless claims are usually settled within a few hours or days, while reimbursement claims may take up to 30 days.
- What documents are required for claim processing?
Common documents include the claim form, hospital discharge summary, bills, prescriptions and diagnostic reports.
- Can I claim for home treatment?
Some insurers cover domiciliary hospitalisation, but only under specific conditions. Check your policy details.
Conclusion
Claim rejections in health insurance can be disappointing, especially during stressful times. However, most rejections happen due to avoidable errors like non-disclosure, missed deadlines or lack of understanding of policy terms. If you have a family health plan or an individual health insurance policy, being informed and proactive is key to ensuring your claim is processed smoothly.
Disclaimer: The information provided in this blog is for educational and informational purposes only. It is not intended as a substitute for professional advice, diagnosis or treatment. Please consult a certified medical and/or nutrition professional for any questions. Relying on any information provided in this blog is solely at your own risk, and ICICI Lombard is not responsible for any effects or consequences resulting from the use of the information shared.