How Hidden Health Issues And Excessive Hospital Bills Can Cause Claim Rejections? |
New Delhi [India], December 20: There are a lot of reasons that can result in the claim being rejected by health insurance providers. The following are some of the most common reasons and the steps that can help you avoid these. It is always a good idea to read your policy documents to get a better understanding of the policy and reduce the chance of rejection.
One of the primary reasons to get a health insurance plan is to receive financial assistance during medical treatments. Unfortunately, quite a few policyholders have their claims rejected for a number of reasons. And claim rejections in such times can be extremely frustrating and overwhelming. These situations can be avoided. Being a bit careful with certain things during the health insurance claim process can help you immensely.
Hiding health-related issues from insurance providers and excessive hospital bills are two major reasons for claim rejections. However, there are a lot of other reasons and factors which can result in the same.
Common reasons for claim rejections
The following are some of the most common reasons for which claims can be rejected by insurance companies. Being aware of them and taking preventive measures will help you overcome them.
1. Waiting period: Most have some sort of waiting period for certain ailments. If a policyholder files for a claim during this waiting period, the chances of claim rejections are quite high simply because they are not yet eligible for the claim.
2. Lapsed insurance: It is always recommended that you renew your policy well before its due date. Failing to renew the policy on time can lead to a policy getting lapsed. If a policy has lapsed or expired, your claims will certainly be rejected by the insurance company. Making a note of the due date on your digital calendar can help you avoid such situations.
3. Pre-existing conditions: A common reason for insurance companies to reject claims is pre-existing medical conditions. If the policyholder fails to mention any pre-existing medical conditions, it comes across as a failure to disclose important information and the cause for claim rejection. It is always a good idea to mention any pre-existing conditions and to be as transparent as possible while buying new health insurance plans. A recent survey shows that about 25% of all claims are rejected due to failure to disclose lifestyle-related medical conditions such as hypertension and diabetes. Pre-existing diseases usually refer to medical conditions that the policyholder had contracted even before buying the policy. If you want to buy a health insurance plan and have any of these pre-existing conditions, it is advisable to mention the same to the insurance provider. After undergoing a waiting period, you can file claims for those medical conditions as well.
4. Delay in filing a claim: Almost all insurance providers have a timeline within which you must file your claim requests. Should you fail to adhere to that timeline, the chances are quite high that your claim can be rejected by the insurer.
5. Sum insured exhausted: In certain cases, if a policyholder has already filed for claims in the same year and has exhausted their sum insured, the chances of rejection are quite high. To avoid such situations, ensure that you are aware of the total sum insured and the total claim amount for the year before filing any claims.
6. Missing documents: When you file a claim for your health insurance plan, you will be required to submit supporting documents along with it. During the claim process, insurance providers usually inform policyholders about all the documents that are needed for the process. Should a policyholder fail to provide any of these documents, a claim can be rejected. Insurers also provide a time frame for submitting any of the supporting documents. Ensure that you submit them within the same time frame.
7. Inflated bills: Though it is not a very common occurrence, certain hospitals are known to inflate medical bills when it comes to insurance claims. Insurance providers have their own empanelled doctors, and they review all claim requests. If the doctors sense any sort of foul play or sense inflated bills, they can recommend cancelling such claims. To avoid such occurrences, asking for an update on the bills on a regular basis and asking for details of the charges can help you.
8. Incorrect diagnosis: Since the insurance providers review all claims with their empanelled doctors, any case of incorrect diagnosis can also be rejected. If the diagnosis does not match the medical records and medical condition, the claim can be rejected by the insurance provider.
How to avoid claim rejections?
Whether you have a plan or a family floater plan, claim rejection can be quite difficult to process. Above are some of the major reasons which can lead to claim rejections. However, there are a few simple steps that you can follow to ensure minimal chances of rejection. Here is all that you should do.
1. Terms and conditions: While it might seem a bit tedious, it is always a good idea to go through the terms and conditions of health insurance plans. It can help you avoid any confusion and make sure that your claims are smooth.
2. Cashless claims: One of the perks of a health insurance plan is the option to opt for a cashless claim. To avail yourself of a cashless claim, you can visit a network hospital and undergo medical treatment. Your insurance provider will settle the bills with your hospital directly. In such cases, the chances of claim rejections are quite low since insurance providers pre-authorise the treatment expenses.
3. Provide accurate information: Providing accurate information to your health insurance provider is one of the fundamental aspects of buying a new policy. While buying the policy, if you are transparent and provide all medical information and medical history accurately, you can increase the chances of your claims being accepted.
4. Timely claims: If you have paid for medical treatment out of pocket and wish to file a reimbursement claim, it is crucial to do it on time. Make sure that you inform your insurance provider about the hospitalisation and ask them about the subsequent processes. Providing them with the necessary documents on time will help you get through the claims without any major hassles.
5. Notify pre-existing conditions: It is in your best interest to inform your insurance provider of any pre-existing conditions that you might have. It shows transparency from your end and eliminates any chances of claim rejections due to pre-existing conditions. Apart from the above, making it a habit to renew policies before their due date can also help you in the process. Renewing the policy on time will ensure you always have access to the policy, and there are no possibilities of a policy lapse.
Conclusion
Failure to disclose any pre-existing medical conditions and inflated hospital bills can result in a higher claim rejection of senior citizen health insurance plans as well as standard health plans. To avoid finding yourself in such situations, you must follow the steps mentioned above. Following the above steps and being a bit careful with your policy can go a long way in reducing the chances of claim rejections.
Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.
