Avoid Health Insurance Claim Rejection
Your Insurance claim denied despite paying premium, Know reasons of cashless health claim rejection
Health insurance claim: Treatment and medical expenses are very expensive presently. The hospitalization expenses can ruin your financial health and may even force you to sell your hard-earned assets. The solution to this is buying health insurance. The health insurance is boon to the people having less income sources and due to uncertain and unavoidable circumstances need to spend high on treatment while hospitalization. Many companies are offering health cover to their employees which may be cashless or reimbursement of medical expenses. But people who do not have adequate coverage, should buy health insurance with enough coverage as per inflation and average hospitalization cost.
Types of health insurances
Typically, there are two types of health insurance, which are cashless insurance and reimbursement of medical expenses. Cashless health insurance is called when you do not have to pay hospitalization expenses upfront and the insurer pays all the covered expenses.
Expenses covered under health insurance –
Generally, all hospitalization expenses are covered under health insurance. Some of the expenses which are covered by health insurance are hospital bed charges, hospital room charges, medicines, doctor visits, ICU expenses etc. However, consumable items are not covered under health insurance. You can always demand a list of expenses from the hospital to know what expenses are paid by the insurer.
Reasons of health insurance claim rejection –
It’s important for you to know the reasons why health insurance companies deny claims and how to avoid claim rejections. The rejection of a claim can be of two types. Either insurer rejects the full claim amount, or they deny paying cashless benefits.
Reasons of rejection of cashless benefits
When cashless benefits are denied by the insurer, you need to manage funds and arrange it immediately so start the hospitalization process. Arranging immediate cash may be difficult for the people not having many sources or networks. Hence it is good to know how cashless insurance is processed and reasons for rejection of cashless claims.
1. Cashless claim is available only in network hospitals of insurer companies.
This is the main reason why cashless claims are rejected by insurers. All the insurance companies have their network hospitals. If a person who has bought health insurance gets admitted to network hospitals then only cashless claim is processed else the person may claim reimbursement of expenses. Hence it is important to know the list of network hospitals of an insurance company before purchasing health insurance.
2. Prior intimation of planned hospitalization is not given to the insurer.
For planned medical expenses like surgery, you should intimate the insurer well before the hospitalization date and get the estimated amount sanctioned. The claim amount is not restricted to the sanctioned amount and can be increased if required. Sudden admission in some cases may be rejected by the insurer for cashless benefit.
3. Disease which is not eligible for cashless benefits.
The insurer may mention the illness which are not covered under cashless benefits while issuing policy. Hence you must read the policy documents and understand the terms and conditions before buying health insurance.
Must Read this before buying a term insurance
Reasons of rejection of health insurance claim completely
There are several reasons due to which a health insurance company may reject your claim, some of these are listed below –
- Violation of the terms and conditions
- Hospitalization for treatment purposes which do not require admission to hospital.
- Claim is not admissible if the hospitalization takes place within the waiting period after a policy is taken.
- Hiding health problems – like having abnormalities in blood sugar level, blood pressure or any disease.
- After taking the policy, not revealing abnormalities in health conditions – like abnormalities in blood sugar level, blood pressure etc. or set in of any diseases.
- While porting a health insurance policy from one insurer to another, all the health conditions and abnormalities present on the date of porting the policy are not revealed.
- Any intentional violation may be treated as fraud, leading to rejection of future claims.
How to avoid health insurance claim rejection?
By taking care of small things and revealing sufficient information, you can avoid rejection of cashless or full health insurance claims. Some of the key measures are discussed below –
- Fulfil all the terms and conditions at the time of hospitalization or availing daycare procedures.
- At the time of filling the application form, understand the terminologies properly.
- Fill the form with utmost care to ensure that no fact is suppressed intentionally.
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