Can Health Insurance Company Reject Claim? Top 20 Reasons

By Okbima 14 Jun 2024
can-health-insurance-company-reject-claim

Health insurance companies can reject a claim for many reasons, including incomplete or incorrect information provided by the policyholder, procedures not covered under the policy, or failure to meet certain eligibility requirements. To avoid claim rejection and ensure you get the best health insurance coverage, it's important to carefully review and understand your policy.

 

Can Health Insurance Company Reject Claim?

Yes, a health insurance company in India can reject a claim under certain circumstances. Some common reasons for health insurance claim rejection are mentioned below.

  • Non-disclosure of pre-existing medical conditions at the time of buying the policy

  • Non-compliance with policy terms and conditions

  • Claim for non-covered services or treatments

  • Filing a fraudulent claim

  • Incorrect or incomplete documentation

  • Claim for treatments not supported by medical evidence

 

Take Control Of Your Health: Compare Health Insurance Now!

 

Top 20 Possible Reasons For Health Insurance Claim Rejection

Health insurance claims in India can be rejected for many reasons. Here are 20 common reasons for such rejections.

  1. Incomplete or Incorrect Information: Providing incomplete or incorrect information during the claim process can cause rejection.

  2. Non-Disclosure of Pre-Existing Conditions: Not disclosing pre-existing medical conditions at the time of policy purchase can cause claim rejection.

  3. Waiting Periods: Claims made during the initial waiting period or the specific waiting period for certain diseases or treatments are often rejected.

  4. Exclusions: Claims for treatments or conditions excluded in the policy document will not be approved.

  5. Claim Not Filed Within the Time Limit: There are specific time period within which claims must be filed. Failing to do so can cause rejection.

  6. Lapsed Policy: If the policy has lapsed due to non-payment of premiums, claims will be rejected.

  7. Non-Covered Treatments: Treatments or procedures not covered under the policy terms will cause claim denial.

  8. Lack of Proper Documentation: Failure to provide necessary documents like medical reports, bills, and prescriptions can cause rejection.

  9. Treatment at Non-Network Hospitals: Some policies require treatment at network hospitals. Getting treated at a non-network hospital can cause claim rejection.

  10. Not Meeting Policy Terms and Conditions: Any terms and conditions mentioned in the policy can cause claims to be denied.

  11. Unapproved Treatments: Getting treatment methods not approved or recognized by the insurer can cause claim rejection.

  12. Fraudulent Claims: Any attempt to submit fraudulent claims will be outright rejected and could cause further legal action.

  13. Claim Exceeds Sum Insured: If the claim amount exceeds the sum insured under the policy, the excess amount will not be covered.

  14. Non-Medical Expenses: Expenses not related to medical treatment, such as administrative fees or service charges, are not covered.

  15. Exceeding Sub-Limits: Some policies have sub-limits for specific treatments. Claims exceeding these sub-limits may be partially or fully rejected.

  16. Unjustified Hospitalization: Hospitalization primarily for diagnostic or evaluation purposes without required medical necessity can cause claim rejection.

  17. Policy Exclusions for Certain Treatments: Some policies exclude specific treatments like cosmetic surgery, dental treatments, etc.

  18. Pre-Authorization Not Obtained: For certain procedures, pre-authorization from the insurer is required. Failing to get it can cause rejection.

  19. Non-Disclosure of Secondary Insurance: If you have secondary insurance and fail to disclose it, claims can be rejected.

  20. Miscommunication or Misunderstanding of Policy Terms: Lack of clarity or misunderstanding regarding the policy terms by the policyholder can cause rejection.

 

Get Covered & Stay Protected: View Health Insurance Plans!

 

Why Do You Get Health Insurance From Okbima?

There are so many reasons to get health insurance from Okbima such as we offer affordable policies, comprehensive coverage, an easy claim process, excellent customer service, etc.

  • Affordable policies: Okbima offers many health insurance policies at competitive rates, making it easier for individuals and families to find coverage that suits their needs and budgets.

  • Comprehensive coverage: Okbima's health insurance policies offer comprehensive coverage for many medical services, including doctor visits, hospital stays, prescription medications, and more.

  • Easy claims process: Okbima makes it simple and convenient for policyholders to file and track claims, ensuring that they receive timely reimbursement for covered expenses.

  • Excellent customer service: Okbima prides itself on providing excellent customer service, with a “Team Of Experts” ready to assist policyholders with any questions or concerns they may have.

  • Flexibility and customization: Okbima offers flexibility and customization options for its health insurance policies, allowing individuals and families to tailor their coverage to meet their specific needs and preferences.

 

Read More:

Can I Buy Health Insurance And Use It Immediately?

Why Health Insurance Premium Increase? Know The Actual Reason

Does Health Insurance Cover Therapy?

Pre-Existing Disease In Health Insurance: List Of Covered Diseases

Health Insurance Age Limit In India: Impact Of Age On Health Insurance Premiums

 

Conclusion

In conclusion, health insurance companies can reject claims for various reasons, including incomplete or incorrect information, non-disclosure of pre-existing conditions, treatment at non-network hospitals, and fraudulent claims. To prevent claim rejection, policyholders need to review and understand their policy terms and conditions. For expert guidance, you can contact “Our Experts”.

 

FAQs

No, health insurance companies cannot reject claims solely based on pre-existing conditions.

Yes, health insurance companies may reject claims for services that were performed out-of-network, unless it was an emergency.

Yes, health insurance companies may reject claims if the policyholder missed a premium payment and the coverage was terminated.

Yes, health insurance companies have a specific time period for policyholders to appeal rejected claims. It's important to review your policy's terms and conditions to understand the deadline for filing an appeal.

Leave a Reply