What to do if Medical Insurance Claim is Denied?

Facing a health concern can be a challenging experience for both the person undergoing treatment and their family. Health insurance provides some reassurance, but a denied claim can be stressful.

Health insurance claims may be rejected for various reasons. If denied, stay proactive. Explore appealing the decision and, if necessary, reapply after addressing initial rejection concerns.

Handling a Denied Medical Insurance Claim

Wondering what to do if health insurance denies claim? Refer to the below process for a clear picture on how to deal with it:

1.   Understand the Cause or Basis for Rejecting a Claim

• Your claim pertains to a disease or treatment not encompassed by the policy's coverage.
• The policy has lapsed or is no longer valid.
• Insufficient details in the application form hinder the support for your claim.
• Inadequate proof or essential documents have not been provided as stipulated.
• The claim is for an individual not included in the policy coverage.

2.   Amend and reapply as needed

• Make necessary changes and restart the claim process.
• Contact the insurance company to confirm adequacy of added details before resubmitting.

3.   Contact an Ombudsman for assistance

• Insurance Act, 1938, permits policyholders to approach Ombudsman for claim settlements, premium discrepancies, policy term violations, or unclear terms.
• Appointed by insurance companies, Ombudsman mediates for dispute resolution between policyholders and insurance companies.
• Verifies facts and issues fair recommendations.
• Keep relevant documents (bills, policy copies, payment receipts, KYC documents) to support the claim.

4.    Draft an appeal letter to address the insurance company.

• Craft a compelling appeal letter or email to address a rejected health insurance claim.
• Explain the reason for obtaining the insurance policy and the specific medical condition involved.
• Provide details about the recommended treatment plan from your healthcare professional.
• Include evidence such as medical prescriptions to support your case.
• Ensure the letter contains factual and necessary information.
• Write why you believe the insurance company should reconsider the appeal against the denied claim.

Conclusion

Claim rejection in health insurance is a common occurrence, but there's no need to be alarmed. Take the time to understand why your claim was denied and what to do when health insurance denies claim, and implement the necessary corrections before submitting it again. If your claim is valid, the insurer is likely to review your appeal positively and ultimately approve your claim.