Written By: Pavitra Sampath | Published : September 10, 2015 6:08 PM IST
Medical insurance is essential for everybody. Not only does it help you when a medical emergency arises, but is also quite handy if and when you or your family member falls ill. But, if your medical insurance claim were to be rejected when you most need the money, would you know why? Most likely not. So, to help you understand what can lead to the rejection of your insurance claim, here are 9 possible reasons it might happen.
An incomplete form: During a medical emergency it is difficult enough to focus on the happenings of ?the day, leave alone filling out a claim form for your insurance company. In such cases it is common for your insurance agent or a person at the hospital to fill up the form for you. A disparity in the details filled out is one of the leading reasons for an insurance claim to get rejected.
Why, you ask? In an interview with Business Today, Shankar Nath, founder of policytiger.com said, "The insurance agent is often not aware of exact customer details and the policy is underwritten with these incorrect details. When a claim is filed, the insurer verifies the information in detail, and if a materially important fact has been inaccurately represented, the claim is rejected." (sic)
This means that when you are buying the insurance your agent fills out the form with inaccurate details, and when you fill out a claim form you fill out details that are different from those present in your insurance policy -- causing your claim to be rejected. You may also like to read about 10 tips to make buying health insurance easier.
What you can do about it:
One of the best ways to avoid this kind of mix-up is to firstly fill out the form yourself with attention to detail. You should also check the copy of your policy right after you buy it and make sure you check it for disparities. If you do find any inform the company so they can make changes.
But if you haven't done that, a good option would be to have all the details of your insurance type and premium with you when you fill the form. If you find yourself in a situation where you are not able to fill out the form (either due to emotional stress or just that you have too many loose ends to tie up at the hospital) have someone else (who knows about your health insurance plan) fill out the form with the aid of your policy.
When your plan does not cover the expenses you are likely to incur: Every health insurance plan has a fixed amount that you are insured for. Known as the sum assured, this is the maximum amount that will be reimbursed in case of medical treatment. If you apply for a claim that exceeds the amount you have been assured for, your claim will get rejected. While you will have the provision to apply again and opt for a percentage of the amount to be reimbursed while the rest will be paid by you, it is still better to get your claim approved in the first instance -- especially in the case of an emergency. You may also like to read 5 to-dos to use your health insurance policy well.
What you can do about it:
While applying for a claim, it is good to apply for the amount you are insured for. This again will require you to know your policy and its clauses well.
Ailment or procedure not covered under your plan: Every health insurance policy has some limitations. Some of them being non-coverage in cases where the person has a pre-existing ailment, outpatient treatment, ambulance expenses, medical care during pregnancy, emergency care benefits and certain procedure that are considered cosmetic and not therapeutic etc. If you claim for a reimbursement when you have undergone a procedure that isn't covered, your insurance company will reject your claim. You may also like to read about these 10 questions you should ask your health insurance company.
What you can do about it:
The only way to side-step this reason for rejection of your claim is to not add it to your total claim amount. While it might be difficult for you to get it removed from your bill, when you file for the total amount, calculate all these exclusions and ask for the amount that is sans these amounts.
Family member not covered: There are a number of different types of health insurance policies out there. So, if you have picked one and nominated a few people in your family, and left someone out of the coverage, your claim will most likely get rejected -- if you try to use it to cover the expenses of their treatment. This can also happen if your plan covers only certain members of your family like your wife and children, but not your parents. You may like to read more about group insurance, and if it covers the health expenses of your family too.
What you can do about it:
Again something that requires some amount of forethought, when you are applying for a claim know who all are covered under the plan. You could also ask your insurance company to add them to your plan -- which will most probably require you to pay a higher premium or change your plan entirely.
Not applying in time: A health insurance policy stipulates that you apply for reimbursement within a certain period of time. In case of an emergency admission, it is usually within 24 hours after the patient has been admitted, and for other types of claim's it can vary depending on the type of policy you have and the treatment being availed. Not applying within the time stipulated, can lead to your claim being rejected.
What you can do about it:
If it is an emergency, make sure you inform someone close to you (a family member or friend) that he/she must file for the claim within 24 hours or as mentioned by the policy. While most hospitals will ask you to fill out the form at the time of admission, which will then be approved by your insurance provider (through a third party administrator), in cases where your claim is not a cashless policy you will need to keep track and apply for a reimbursement.
Not applying as per your type of insurance: Your health insurance policy has a number of inclusions and exclusions. There are add-ons, critical illness benefits and even surgical expense benefits. Your policy may be custom designed to fit your needs. So, if you apply for anything that isn't included in your policy, your claim can be rejected. You may also like to read - A dummy's guide to calculating health insurance premium.
What you can do about it:
Here, knowing exactly what kind of policy you have, helps. Make sure you apply under that particular policy type for the right amount of coverage so that your claim does not get rejected.
Pre-existing conditions that could lead to the current ailment: In most health insurance policies there are certain exclusions. One of the most common type is pre-existing conditions. While there are some policies that give you coverage for the treatment for that ailment -- but only after a period of time -- others might not cover that ailment at all. But what you really need to keep an eye out for is, when your policy excludes that condition, it also indicates that any other ailment that might arise as a complication of that pre-existing condition will also be excluded. In such a case, if your insurance company feels that the ailment you are seeking cover for has risen from your pre-existing condition, it could reject your claim. You may also like to read about pre-existing conditions and how health insurance can help you.
What you can do about it
If your claim has been rejected on these grounds, you do have the option to apply for a reimbursement with doctors notes stating that your ailment is not caused due to your pre-existing condition -- if in fact that is the case. If not, you cannot be covered for the expenses you incurred due to that illness.
Non disclosure while buying the insurance policy: You health insurance policy is designed as per a number factors such as your age, any ailments you might have, where you work etc. In an interview with Business Today, Antony Jacob, chief executive officer, Apollo Munich Health Insurance, said, "Coverage is offered based on the information provided by the proposer on the proposal form and hence any gap between what is declared and the reality at the time of filing claims can be a reason for rejection."
What you can do about it:
Disclose and submit authentic documents at the time you buy your policy.
If the procedure was deemed not necessary: One of the most common reasons for rejection of a health insurance policy is when a service or procedure is deemed 'not medically necessary' by your insurance company. A common trend in certain hospitals -- where a patient is put through a battery of tests and even unnecessary procedures in order to gain maximum revenue. According to Shankar Nath , "Private hospitals, in their quest to generate maximum revenue, perform medical procedures which may not be necessary, on patients covered by a medical insurance policy. The policyholder is also relaxed about it as he mistakenly assumes the money will be paid by the insurance company. The penny drops when the claim is rejected."
What you can do about it:
Knowing what you can and cannot claim under your insurance policy, and not including them in your claim is essential. It is quite difficult to deem if a particular procedure or test is actually required for the ailment you or your loved one is suffering from, and therefore avoiding them can be tough. So, just being informed about what kind of expenses you will be covered for versus the ones you won't, can help prevent any rude shocks later.
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