Have you ever been baffled about why your health insurance claim was denied? Was it incorrect details, missing adjuncts, or the terms of the policy that slipped your mind? Were pre-existing medical issues completely revealed?
Could it have saved you from a rejection if the policy had been renewed on time or even pre-approved? Let’s dive into some of the most common hotspots of policy denials and explore how to circumvent them.
Understanding Health Insurance Claim Rejections
It’s a common perception that insuring oneself with a health policy means that a person will get reimbursed for all medical expenses incurred; thus, he/she is entitled to full medical reimbursement.
However, when the claim gets rejected, the most immediate, visible response is frustration and financial stress that goes with the denial. But is the insurance guilty?
Not necessarily; in many cases, even if the claim covers all the circumstances for which a person is claiming, it happens that the claim has been avoided because of some easily avoidable mistakes. With proper updates and a cautious mind, the chances of denial can be reduced significantly.
1. Hiding Pre-Existing Illnesses
Insurance is based on the principle of “Utmost Good Faith”, according to which both the insurer and policyholder should be transparent with each other. Many people, however, withhold facts related to existing illnesses such as diabetes, hypertension, or heart disease due to the causes of high premiums or certain refusals.
How to avoid it:
- Always share your complete medical history when taking out policies.
- Even the minor ailments, if reported, would make a difference in case such a situation arises again.
2. Ignoring Policy Terms & Conditions
The fine prints are the most neglected things that every insured individual would find himself/her self-once he/she comes to learn that certain treatments will not come under coverage or be subjected to a certain waiting period such as surgeries denoting hernia or cataract that mostly linger on with a waiting period of 2-3 years.
Avoid This:
- Carefully read the fine print in the policy document before signing it.
- Address any of your doubts with your insurance agent or provider.
3. Delaying Policy Renewal
A lapsed policy now means no coverage. It is usually forgotten by many people, which causes problems in getting a claim during emergencies.
Avoid It:
- Activate auto-pay for premium renewals.
- Set calendar reminders for a few weeks before a due date.
4. Submitting Incomplete or Incorrect Documents
Missing or inadequate hospital bills, discharge summaries, and doctor’s prescriptions can delay or deny your claim.
How To Avoid It:
- Make a collection of all medical records appropriately.
- All required documents are to be submitted within the time to the insurer.
5. Treatment Not Covered Under the Policy
Not all the treatment procedures fall under the coverage of policies, for instance, plastic surgery and dental, and fertility treatments are mostly excluded.
How to Avoid It:
- Check the section “Inclusions & Exclusions” in your policy.
- If you require a specialized treatment, add-on covers may also be considered.
6. Skipping Pre-Approval for Cashless Claims
If you enter a hospital for an elective procedure without pre-authorization, the money claim may be denied.
How to Avoid It:
- Inform your insurance company in advance of the scheduled date of admission.
- Follow the cashless claim procedure set out in your policy.
What If Your Claim Is Still Rejected?
- If, despite all precautions, your claim is rejected
- Seek an explicit explanation from the insurance company.
- If still in dispute, elevate the matter to the Insurance Ombudsman.
Conclusion
Health insurance is a form of financial protection, and it must be treated responsibly. Giving correct information, understanding the terms of the policy, renewing on time, and gathering documentation will increase the chances of successful claims. So keep informed and stay covered!