How to Appeal for a Rejected Health Insurance Claim?

The purpose of purchasing health insurance is to avail yourself of coverage in times of medical need. A health insurance claim denial can significantly increase your financial stress. Before moving any further, it is crucial to note that a claim rejection is not a NO for treatment but only for a claim. So, even in case of health insurance claim denial, the policyholder must seek medical care.

In today's time when medical expenses are skyrocketing, it is the health insurance plan that acts as the saviour. Paying from your pocket would be the last choice you wish for.  However, medical billing denials can pose a financial threat to your savings especially in times of a health emergency. So, understanding the claim process is not enough. You must also know what to do if a health insurance claim is denied in India. 

This article will provide information on health insurance claim denial and the process to re-appeal. Stay with us!

Health Insurance Claim Rejection Reasons

Understanding health insurance claim rejection reasons is crucial to address the issue of claim rejection. Only then can you rectify yourself and appeal for insurance coverage. Usually, most of the insurers try to approve the claims within the time frame so that the insured can avail quick healthcare facility. However, not always is the case and health insurance claim denial is the only option left. Common reasons for health insurance denied coverage are:

Wrong Information

If the insured provides wrong or insufficient information in the claim documents, it becomes tough for the team to process details further. Hence in such a situation, the claim is rejected. You may request to raise another claim by filling in the correct details. Make sure to carefully read the information before submitting the form and other documents.

Inadequate Sum Insured

In case of multiple claims, the insured may not have an adequate sum to raise another claim request, which can result in a rejection of the claim. The insured may get the sum insured refilled to raise a claim again.

Claims Against Exclusions

Usually, health insurance plans have a section of exclusions. The health conditions that are not covered in the health plan are termed exclusions. So, a claim for any of the excluded terms is not covered. Read the policy documents carefully to be aware of the exclusions of your policy.

Claim During Waiting Period

Health insurance plans have an initial waiting period of 30 days. During the first 30 days of claim purchase, a claim cannot be raised. In case of pre-existing diseases or maternity claims, the waiting period is usually longer. So, one has to serve the waiting period to be eligible to raise a claim. 

You must note that accident-related claims are covered during the waiting period as well.

An Expired Policy

To avail of the benefits of a health insurance policy, one must have an active health plan. Renewing health insurance before its expiration is crucial to continuing the services. In case your health insurance policy has expired, the claim will automatically be rejected. In such a case, you will either have to renew or purchase the policy again.

Appeal for Denied Health Insurance Claim

Now that you know the probable reasons for health insurance claim denial, let's understand how you can appeal for a denied claim. Here is a detailed solution to each claim rejection reason:

Solutions for Claim Rejections

• In case you have submitted wrong or insufficient information, you can raise a claim again by submitting the correct information.
• Get in touch with the insurance executive to get clarity on the exclusions and inclusions of the plan. It helps you make an informed decision the next time you need to raise a claim. For diseases or health conditions that are not covered in a health plan, the claim cannot be raised.
• If your policy has expired and the grace period has also passed, you may have to purchase the policy again to get the desired coverage in the future.

Ombudsman Appeal

Under the Insurance Act of 1938, the government appointed an insurance Ombudsman to help people settle their claim disputes with their insurance company. If you have a dispute regarding a delayed claim, unsatisfied claim settlement, premium disputes, etc., you can request an Ombudsman to settle your dispute.

Appeal Letter to the Insurance Company

Another step involved in seeking rejection approval from the insurance company is to write a letter of appeal. Let’s say, you have a senior citizen health insurance plan from Care Health Insurance and for a reason if your claim was rejected you may write to Care Health Insurance regarding health insurance denied coverage.

You will be reverted back immediately with a solution to your query. Depending on our team's response, you can do what is necessary to successfully receive the policy benefits.

When a health insurance claim is rejected, the insurance company usually provide a protocol for raising a claim again. The reason along with the solution to the claim rejection is usually well described. However, in the event of an unsatisfactory claim settlement or rejection, you may then appeal to an insurance Ombudsman or to a court.

Final Word!

Health insurance claim rejection is an unwanted situation for anyone, especially during medical emergencies. In case of an urgent medical requirement, it is best to go for the treatment even if the insurance claim is rejected. Once the medical treatment procedure begins, you may continue looking into denial of your health insurance claim. You can reapply for the claim or continue with the reimbursement claim. Upon successful claim approval, you will be assured of guaranteed coverage as per your health insurance plan.

Today, when all the details of a health insurance plan are available online, the chances of getting a claim rejected are quite low. As a first-time policy buyer, you can get thorough with the claim process before you raise a claim to avoid rejections. We are always enthusiastic to help you out with insurance grievances.

>> Also Read: 5 Best Ways to Avoid Medical Insurance Claim Rejection

Disclaimers: The above information is for reference purposes only. For more details about the health insurance plans and their benefits please refer to the sales prospectus, policy terms, and conditions.