Why Health Insurance Claims Are Rejected?
  • What are health insurance claims?
  • Claim rejection reasons
  • How to avoid claim rejections?
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Why Health Insurance Claims Are Rejected?

The consistent rise in lifestyle-related ailments and increasing medical inflation showcased the importance of health coverage. Investing in a health insurance plan is crucial for your financial security. With a health insurance plan, you are entitled to avail of features like hospitalisation coverage, daycare procedures coverage, AYUSH treatments, international coverage, etc.

Availing of medical care is a hassle-free process with cashless hospitalisation and 30-day claim settlement. However, there are multiple instances wherein health insurance claims are rejected. A large amount of health insurance claim rejections happen due to a lack of information regarding one's policy terms and conditions.

In this article, we are uncovering the 8 most common reasons for rejected health insurance claims.

8 Health Insurance Claim Rejection Reasons

Scroll to learn the 8 most common reasons for rejected health insurance claims and learn how to avoid them for successful policy continuation and smooth claim process.

  • Filing Health Insurance Claims Before Fulfilling Waiting Period

    Generally, a health insurance plan includes multiple waiting periods for covered medical treatments. A common mistake insurance holders make is filing for a claim without serving the specified waiting periods of a health insurance plan.

    This leads to rejected health insurance claims. Claim rejections can be easily avoided by reading the terms and conditions of the health insurance plan carefully.
  • Not Disclosing Pre-existing Diseases

    Make sure to reveal your pre-existing diseases such as diabetes, high blood pressure, etc.

    Not all health insurance plans will cover pre-existing diseases that you are diagnosed with. When you file claims for such PEDs your claims might get rejected leaving you with a bitter experience.
  • Incomplete Information

    One of the most common reasons for health insurance claim rejection is submitting incorrect or incomplete information during claim submission. When filing a health insurance claim, it is important to submit all the information asked by the health insurer in your claim form.

    Information like your name, doctor's prescriptions, age, and all other information should be included according to the health insurers' requirements.
  • Untimely Claim Intimation

    Health insurance claims are often rejected due to untimely claim intimation. All health insurance providers have a specified time limit within which you must notify them about your planned or emergency hospitalisation. If you forget to inform your health insurer within the given time limit, your claim will be rejected causing further problems.
  • Surpassing Base Cover Sum Insured

    The sum insured is the maximum amount a health insurance provider will provide you during the policy term. In case you have exhausted the given sum insured amount, your cashless claims exceeding your given sum insured limit will be rejected by the health insurance provider.
  • Not Reading Exclusions

    Another common reason for health insurance claim rejection is filing claims for diseases that are mentioned in exclusions and may not be covered by your health insurance plan. It is common to ignore the exclusions of a health insurance plan, as many of us are concerned only about inclusions.

    Make sure to read the exclusions of all illnesses that are mentioned in the exclusions of your health plan.
  • Misinterpretation of Information

    A lot of health insurance plans come with mandatory co-pay clauses with some treatments that are often ignored by customers. In case, the co-pay amount mentioned in the policy schedule is not paid by you, the chances of health insurance claim rejection increase.
  • Health Insurance Lapse

    Health insurance plans lapse in case you miss out on paying premiums that are due, stripping you off the coverages. Filing a claim based on a lapsed health insurance policy will lead to claim rejections.

How To Avoid Health Insurance Claim Rejection?

Here are a few tips and tricks which you must adhere to avoid rejected health insurance claims:

  • Carefully read the terms and conditions of the health insurance policy you purchase to minimize the chances of claim rejections
  • Offer correct and detailed medical information at the time of health insurance policy purchase and do not hide any medical history to claim your health insurance
  • Intimate your health insurance provider within the given timeline provided in case of any emergency or planned hospitalisation
  • Disclose all your pre-existing health conditions at the time of policy purchase
  • Make sure to renew your health insurance policy on time to avoid claim rejections in health insurance

Wrapping It Up

Health insurance claims are crucial for every customer. Having claims rejected in case of an emergency can be stressful and lead to a negative experience. To avoid such instances you must understand the reasons for rejected health insurance claims. Avoid health insurance claim rejections completely with the above-mentioned tips.

To know further about health insurance claim rejections, contact our insurance experts at PolicyX.

Why Health Insurance Claims Are Rejected?: FAQ's

1. What is a health insurance claim rejection?

When the health insurer denies your claim and does not process the cover amount, it is known as health insurance claim rejection.

2. Why are health insurance claims rejected?

Health insurance claims are rejected for multiple reasons such as:

  • Incomplete information in the claim form
  • Claiming during the waiting period
  • Not reading all the exclusions thoroughly
  • Filing a claim after a health insurance lapse
  • Surpassing base sum insured cover

3. How to avoid health insurance claim rejection?

To avoid such instances, make sure to read the terms and conditions carefully along with understanding the exclusions of the health insurance plan.

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Simran Kaur Vij

Written By: Simran Kaur Vij

Simran is an insurance expert with more than 3 years of experience in the industry. She may have all the answers to your insurance queries. With a background in Banking, she proactively helps her readers to stay on par with all the latest Insurance industry developments.