75% of health insurance claims rejected; here’s how to avoid rejection

Having health insurance is crucial for ensuring financial protection in case of medical emergencies. However, it is disheartening to know that a majority of claims get rejected by insurance companies.

According to Policybazaar, 75% of health insurance claims in India are rejected. This highlights the need for policyholders to have a better understanding of health policies and avoid common pitfalls that lead to claim rejections. 

Let's take a closer look at the reasons behind these rejections and how policyholders can avoid them. 

• Many policyholders file claims before the waiting period is over, resulting in over 18% of rejections. 
• 25% of claim rejections occur due to claims filed for ailments not covered (16%) or OPD and daycare claims that are not payable (9%). 
• 4.5% of claims are rejected because they were wrongly filed. Although a smaller percentage, 2.12% of claims get rejected due to limit exhaustion. 
• A significant proportion of 25% of claims get rejected because policyholders fail to disclose pre-existing conditions like Diabetes or Hypertension, as per data. 
• Over 16% of rejections occur due to unsubmitted query reverts. 
• 4.86% of claims are rejected for unjustified hospitalisation. This includes cases where hospitalisation didn't meet the required criteria as per the policy. 
• An interesting observation from the data is that the sum insured range plays a significant role in claim rejections. Surprisingly, the least number of claims (2%) were rejected in the sum insured range of ₹50 lakh and ₹1 crore. On the other hand, the highest number of rejected claims (53%) were found in the sum insured category of ₹5 lakh. 

How to avoid rejection of health insurance claims? 

Submitting a health insurance claim can sometimes be a daunting process, but having it rejected can be even more frustrating. To ensure a smooth and successful claim experience, follow these essential tips:

Verify coverage: Before seeking any medical treatment, thoroughly review your policy to understand what expenses are covered and any pre-authorization requirements.

Provide accurate information: Double-check that all personal details, including name, address, and policy number, are correctly entered on the claim form. Ensure medical codes and treatment descriptions are accurate as well.

Keep documentation: Maintain records of all medical bills, prescriptions, and invoices, as well as any supporting documents related to your claim. This will expedite the process and protect against discrepancies.

Submit claims promptly: File your claim as soon as possible to avoid missing any deadlines imposed by your insurer. Timely submission increases the chances of receiving your reimbursement.

Follow procedures: Understand the specific claim filing requirements of your insurance company. This may include filling out specific forms, attaching necessary documents, or adhering to certain billing practices.

Seek pre-authorization: If your policy necessitates pre-authorization for certain treatments or procedures, make sure you have obtained the necessary approvals before proceeding. Failure to do so may result in claim denial.

Review exclusions and limitations: Familiarise yourself with the exclusions and limitations stipulated in your policy. Knowing what is not covered can help you avoid using services or treatments that are not eligible for reimbursement.

Communicate with your healthcare provider: Maintain open communication with your healthcare provider regarding your insurance coverage. Discuss treatment options and costs to ensure they align with your policy, minimising the risk of claim rejection.

Review the claim before submission: Before sending your claim, carefully review all the information provided. Check for any errors, missing details, or inconsistencies that could lead to a rejection.

Be persistent: If your claim is rejected, don't lose hope. Study the reasons for denial and work with your insurer to understand the issue. Appeal the decision if necessary to ensure you receive the coverage you deserve.

By following these steps, you can avoid common pitfalls that often result in health insurance claim rejections. Remember to stay informed, communicate effectively, and be meticulous in your documentation to increase the chances of a successful claim experience.