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What to do when health insurance claim gets rejected?

The increasing medical costs are a burden on a common man. That is the primary reason why many individuals purchase a health insurance plan and protect themselves against huge medical costs. A health insurance policy pays for the covered medical expenses and grants peace of mind. But, what if your health claim gets rejected? Have you considered your options then? Though you do not like it, many times your health insurance claim might get rejected for various reasons. This rejection comes as a shock especially since you are burdened with your medical expenses which would have otherwise been covered by your health plan. Do you know what should you do when your health claims get rejected? If you don’t, here are some suggestions:

  • Understand the reason for rejection
The insurance company does not reject your health claims on a whim. There are substantial reasons for any rejection. So, the first thing which you should do is understand the reason for rejection of your claim. Usually, claims get rejected for the following reasons:
  • You have made a claim within the waiting period for pre-existing diseases.
  • Your policy lapsed when you made a claim
  • You make a claim for a contingency which is specifically excluded from coverage. For instance, medical treatments faced due to drunk driving or participation in hazardous activities are not covered in a health plan.
  • You Sum Insured has been already exhausted due to previous claims in the year, etc.
Find out why your claim has been rejected before taking any further step.

  • Go through your policy document
If the rejection is due to coverage limitations, you should check your policy documents to find out whether the claim you made was covered by the plan or not. Look through the promised coverage benefits before you approach the insurance company for further clarifications.

  • Check your claim form
Most often than not, claims get rejected because of mistakes made in filling up the claim form. To see whether you have committed the same mistake or not check the claim form which you have filled and submitted. See if you have filled the claim form correctly and check if all the necessary details asked in the form have been duly furnished.

  • Contact the insurer’s TPA
Many insurance companies engage the services of a Third Party Administrator (TPA) to act as intermediaries between them and the policyholder for claim settlement. TPA collect information from you and submit it to the insurer. It might happen that your claim got rejected due to errors on the TPA’s part. To eliminate the possibility, contact the TPA and find out if all details have been communicated correctly to the insurance company. Moreover, the TPA might also help you understand the cause of rejection.

  • Check the documents submitted
Health insurance claims involve submission of various medical documents. If any document is missing, your claim might get rejected. So, double check all the documents you have submitted the documents required by the insurance company for processing the claim. If any document is missing you should submit it which might help you to get your claim settled.

  • Gather proof and approach an insurance ombudsman
If you feel that your claim has been rejected without any justifiable reason and the insurance company is to blame, you can approach the insurance ombudsman for redressal. Before doing so, you should arrange for medical proofs substantiating that your claim should have been paid. Then approach the ombudsman and submit your grievance. The ombudsman would then gather all relevant information and facilitate your claim settlement with the insurance company. Alternatively, you can also file your case in a judicial court (an insurance ombudsman is a non-judicial authority). That would be called an appeal and would involve legal proceedings.Rejection of your health insurance claim, though undesired, is possible. There are various reasons for such rejection. In some instances of rejection where you had made a mistake, you can rectify your mistake and get your claim settled. However, in other instances, you might not get your claim settled. Legal recourse is an option for you where you can appeal for settlement in a recognized court of law. Insurance ombudsmen can also be approached for grievance redressal. Whatever you do, follow the above-mentioned tips when your claim gets rejected.

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