Top common reasons why health insurance claims are denied

Many of us don’t understand the language of health insurance policies. So, your insurance claim may be denied because you missed out on important conditions laid down in technical terms in the policy document. Sometimes your claim may get rejected due to your negligence. You must understand the claim process in and out. It is wiser to prevent claim rejection than to take corrective action afterwards. Therefore, understanding the grounds for a health insurance plan claim’s denial is essential. 

Reasons why your claim for health insurance gets rejected

If you can prove to the insurer that your claim was legitimate after it is rejected, the insurer may consider your claim. However, before making corrections, you must first understand why it was denied. Let us understand why your health insurance plan claim could be rejected 

  • Making a claim during the waiting time

Typically, there is a 30-day waiting period attached to most health insurance coverage. Hospitalisation due to certain illnesses and disorders is subject to waiting time. For example, your health insurance covers accident-related hospitalisations from the beginning of the coverage. If you have a critical illness policy, the claim is provided if you lived for at least 30 days after the condition was diagnosed. 

Pre-existing ailments or diseases are problems that you and your family had before acquiring family health insurance coverage. In most cases, health insurance providers do not cover pre-existing health issues without a required waiting time of 2-4 years. Your health insurance claim will be denied if you file one of these ailments during the waiting period. 

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  • Providing false information

Quite often people ask their insurance agent to fill up the application form so as to save time. However, only the applicant should complete the application form. Unaware or not, an agent could deliver incorrect information if they don’t have all the facts on you. Similarly, many candidates provide false information while completing the application. Your health insurance plan claim may be rejected if there are errors in your name or if you try to conceal essential details. Furthermore, the insurer can cancel the health insurance coverage if the applicant knowingly provides false information.

  • Failure to timely renew the insurance

This is one of the most common reasons for claim rejection – not renewing the policy in time. Sometimes, you neglect to renewal reminders of your health insurance or believe you will do so before it expires. The insurance provider will, however, deny the claim if the insured needs health insurance coverage to fill this gap. Therefore, it is advised to choose an auto-debit requirement so that the premium for your health insurance plan is automatically deducted from your designated bank account and renewed.

  • Hiding medical history or existing illnesses:

Sometimes individuals believe disclosing their medical history may result in a policy being rejected or a higher premium. The insurer will not accept any claims resulting from your pre-existing health condition if you hide your medical records. Similar reasoning applies to various lifestyle inquiries when you buy or renew insurance coverage, such as whether you smoke. The insurance provider will not pay for treatment costs if your uncovered smoking habit results from a medical issue. Even if your premium may be higher, you won’t be responsible for paying for any medical problems resulting from the stated disorders.

  • Failure to timely notify the insurer

Another factor that might cause your claim to be denied is failing to notify the insurance provider within the allotted time. You or your family may not be able to submit the family health insurance claim immediately after a severe accident. Usually, insurance companies offer enough time window to file a claim. However, depending on the terms and conditions, you must notify your insurance provider within 24 to 48 hours following the hospitalisation. If you cannot inform the insurance provider, the nominee or another authorised person must do so at the very least.

  • Ignoring the terms and conditions

Many consumers disregard the advice of financial professionals to study all policy-related documentation thoroughly before purchasing a health insurance policy. A policyholder must be aware of all pertinent information about the policy. Policy exclusions are among the things you must know. Each health insurance plan contains a list of exclusions specifying the circumstances not covered by that plan. From insurance to insurer, the list of exclusions varies. Insurance providers do not accept claims relating to such exclusions since they have already stated that your policy would not cover specific scenarios. Many consumers regret not reading the exclusions list when they file a claim and learn the insurer would not accept it. To make an educated choice and prevent potential problems, ensure you have read all the policy papers. Before you get a policy, be careful to ask the insurer about any terminology in the paperwork you do not understand.

  • Claiming more than your insured amount

You should select health insurance following your unique needs and health status. However, most consumers base their health coverage decision on the cost involved. This can result in inadequate coverage in the event of a medical emergency. For example, suppose you submit a claim for more than your sum covered. Then, the claim will be given for the qualifying amount, and you will have to bear the additional medical costs. Therefore, it is wise to consider the size of your family, medical history, and potential future medical expenses. Then, if a medical emergency happens, having sufficient coverage for family health insurance will help you financially.

You may get the most out of coverage if you research thoroughly and select the add-ons most suited to your needs. But, your claim may be denied if you make hurried selections while purchasing or submitting your claim. Therefore, to prevent claim rejection, you should thoroughly understand your insurance coverage, preferably from the moment of purchase. The next step is to compare health insurance plans online to see what is available and choose the one that best suits your needs. Additionally, it is essential to keep track of all your paperwork, including pre-and post-hospitalisation costs, discharge summaries, and investigation findings.