How to Avoid Rejection in Health Insurance Claim

Securing health insurance is a crucial step in protecting your financial well-being during medical emergencies. However, the concerning statistic that 75% of Health Insurance Claims in India face rejection highlights the need for policyholders to thoroughly understand their coverage. In this article, we explore the common reasons behind claim rejections and provide actionable tips for policyholders to steer clear of these pitfalls.

🔸Understanding Common Rejection Causes:

1. Early Claims During Waiting Period: Approximately 18% of claim rejections stem from policyholders filing claims before the completion of the waiting period. It’s crucial to grasp the nuances of waiting periods in health insurance policies.
2. Claims for Non-Covered Ailments: A significant 25% of rejections occur due to claims for ailments not covered (16%) or non-payable OPD and daycare claims (9%). Understanding policy inclusions is key to avoiding these pitfalls.
3. Incorrectly Filed Claims: 4.5% of claims face rejection due to incorrect filing procedures. Navigating the paperwork maze and adhering to proper filing guidelines is imperative.
4. Limit Exhaustion: 2.12% of claims get rejected because policyholders exceed their coverage limits. Managing coverage wisely becomes paramount to avoid this scenario.
5. Non-Disclosure of Pre-Existing Conditions: A substantial 25% of rejections occur when policyholders fail to disclose pre-existing conditions like Diabetes or Hypertension. Full transparency about one’s health history is vital.
6. Unsubmitted Query Reverts: Over 16% of rejections occur due to unsubmitted query reverts. Responding to queries promptly is essential for a smooth claims process.
7. Unjustified Hospitalisation: 4.86% of claims face rejection due to unjustified hospitalization not meeting policy criteria. Ensuring that hospitalization aligns with policy standards is crucial.
8. Impact of Sum Insured Range: Data shows that claims in the sum insured range of ₹5 lakh have the highest rejection rate at 53%, while the ₹50 lakh to ₹1 crore range has the lowest at 2%. Understanding rejection rates across coverage ranges is essential.

🔸Tips to Avoid Health Insurance Claim Rejections:

• Verify Coverage: Before seeking medical treatment, thoroughly review your policy to understand covered expenses and any pre-authorization requirements.
• Provide Accurate Information: Double-check all personal details and ensure accurate entry of medical codes and treatment descriptions on the claim form.
• Keep Documentation: Maintain records of medical bills, prescriptions, invoices, and any supporting documents related to your claim.
• Submit Claims Promptly: File your claim promptly to meet insurer deadlines, increasing the likelihood of reimbursement.
• Follow Procedures: Understand your insurance company’s specific claim filing requirements, including filling out forms, attaching necessary documents, and adhering to billing practices.
• Seek Pre-Authorization: Obtain necessary pre-authorizations for treatments or procedures if your policy requires it, to avoid claim denial.
• Review Exclusions and Limitations: Familiarise yourself with exclusions and limitations in your policy to avoid using services or treatments not eligible for reimbursement.
• Communicate with Healthcare Provider: Maintain open communication with your healthcare provider to ensure treatment options and costs align with your policy.
• Review Claims Before Submission: Carefully review all information provided in your claim to check for errors, missing details, or inconsistencies.
• Be Persistent: In case of claim rejection, study the reasons and work with your insurer to understand the issue. Appeal the decision if necessary to secure the coverage you deserve.

By following these steps, policyholders can navigate the complexities of health insurance claims, significantly reducing the risk of common pitfalls that lead to rejections. Stay informed, communicate effectively, and maintain meticulous documentation to enhance the likelihood of a successful claim experience. In the realm of health insurance, knowledge truly is power.

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