How to ensure that your health insurance claim does not get rejected?
Kunal Shah, a 35-year-old businessman, was diagnosed with Covid and was admitted to a private hospital for nearly 20 days. On his return home, he was planning to file a reimbursement claim with his health insurer for the covid medical expenses. But he was very caught up with his business work, and he completely forgot to submit the claim within 7 days of discharge. Finally, he managed to submit all the necessary documentation and bills after 2 weeks, but the insurer rejected the claim due to the late filing of the claim request.
The real intention of buying a health insurance policy is to avoid bearing the huge medical treatment bills for yourself and your family. The insurance company assures you to provide coverage towards any health risks, based on the sum insured and premium you choose. But there are situations when health insurance claims might get rejected, putting those involved into a lot of stress. But before moving in deep, do you know the meaning of the claim and the claim settlement process in health insurance?
How to file an Insurance Claim?
Health insurance plans are plenty in the market, but the claim settlement process is done in only two ways: 1) Cashless and 2) Reimbursement.
- In cashless claims, the policyholder can get admitted to any network hospital and avail treatment without any payments. All the medical expenses are settled by the insurer directly with the hospital.
- In reimbursement claims, the medical expenses are reimbursed to the policyholder after discharging from the hospital. So, the policyholder must pay the bills during his stay for treatment, and on discharge, the reimbursement claim can be made to the TPA or insurer with all the necessary bills and medical records.
6 Top Ways to Avoid Health Insurance Claim Rejection
- Provide Correct Information
- Know about the Waiting Period
- Policy Inclusions & Exclusions
- File Claim on Time
- Submit Required Bills and Documentation
- Claim Settlement Ratio
1. Provide Correct Information
The health insurance application form is long and asks for many details from the individual. There is a high chance that the provided information is wrong or mismatched. But it could be the reason for your health insurance claim rejection at the need of the hour. Therefore, make sure to include all the correct details about your health such as smoking habits, drinking habits, age, income level, education, family members, other policies, medical history, pre-existing diseases, etc., and do not conceal any information from the insurer to reduce the premium outgo. If the information is found to be false in the future, then your claims could get rejected and the policy canceled.
2. Know about the Waiting Period
Once you buy a health insurance policy, the coverage on your health starts immediately, but you cannot begin to filing claims. There is a certain period called the ‘waiting period,’ which is the amount of time you will need to wait to utilize certain unique benefits of the policy fully. If you file a claim within this period, it shall get rejected right away. While the waiting period of most health insurance policies ranges between 1 to 4 years, reading the terms of the policy shall give you better clarity on the duration of waiting or cooling period for specific ailments/ treatments.
3. Policy Inclusions & Exclusions
In a health insurance policy, getting to know what’s included and what is excluded in the coverage is essential. For example, you cannot claim the treatment costs for weight loss treatment, infertility, dental treatments, sexually transmitted diseases, etc. If you file a claim request without going through this list, then the claim shall get rejected. The list of inclusions and exclusions of the health policy can be known from the policy documents.
4. File Claim on Time
You are required to file the claim for the treatment undertaken within the specified time for it to be taken for processing by the insurer. In case of cashless claims, intimation for emergency conditions must be made to the TPA or insurer within 24 hours of hospitalization health insurance. For reimbursement claims, the policyholder must produce all the necessary proofs to the insurer or TPA no later than 15 days from the date of discharge from the hospital.
Few policies specify a different time frame for filing the insurance claims. So you are needed to know about this timing based on the policy that you have chosen to make sure your claims are not rejected for filing late.
5. Submit Required Bills and Documentation
Furnishing less information about the medical treatment and missing to submit few more documents features in the list of common health insurance rejection reasons made by many policyholders. The insurance company requires all the relevant proofs, reports, documentation, etc., to verify your claim request and approve. If you forget to attach any vital proof or report or a bill, it shall be considered invalid information, and the claim shall get rejected. So do not leave behind any of your documents related to your treatment with the hospital, as it might be crucial for the insurer to approve your claim.
6. Claim Settlement Ratio
Don’t want your medical insurance claim rejected? Then, pay attention to health insurance companies claim settlement ratio (CSR) while buying a health policy. The claim settlement ratio is the total number of claims settled by the insurer compared to the total number of claims received by them in a particular year. While a high CSR means the insurer settles most of the claims on time, a low CSR means the claim rejection rate is high due to various reasons. Therefore, it is always recommended to buy a policy from an insurance company with high CSR to avoid your claims getting rejected.
Taking a risk with your life is not advisable, and so is the reason why a health insurance policy is usually taken. But after availing of the policy, being clear about the claim settlement process is very important as you and your family shouldn’t be cited any common health insurance policy rejection reasons during the claim filing process. If followed religiously with carefulness, the above tips shall help you ensure that your health insurance claim does not get rejected.