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.
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
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Health insurance claims in India can be rejected for many reasons. Here are 20 common reasons for such rejections.
Incomplete or Incorrect Information: Providing incomplete or incorrect information during the claim process can cause rejection.
Non-Disclosure of Pre-Existing Conditions: Not disclosing pre-existing medical conditions at the time of policy purchase can cause claim rejection.
Waiting Periods: Claims made during the initial waiting period or the specific waiting period for certain diseases or treatments are often rejected.
Exclusions: Claims for treatments or conditions excluded in the policy document will not be approved.
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.
Lapsed Policy: If the policy has lapsed due to non-payment of premiums, claims will be rejected.
Non-Covered Treatments: Treatments or procedures not covered under the policy terms will cause claim denial.
Lack of Proper Documentation: Failure to provide necessary documents like medical reports, bills, and prescriptions can cause rejection.
Treatment at Non-Network Hospitals: Some policies require treatment at network hospitals. Getting treated at a non-network hospital can cause claim rejection.
Not Meeting Policy Terms and Conditions: Any terms and conditions mentioned in the policy can cause claims to be denied.
Unapproved Treatments: Getting treatment methods not approved or recognized by the insurer can cause claim rejection.
Fraudulent Claims: Any attempt to submit fraudulent claims will be outright rejected and could cause further legal action.
Claim Exceeds Sum Insured: If the claim amount exceeds the sum insured under the policy, the excess amount will not be covered.
Non-Medical Expenses: Expenses not related to medical treatment, such as administrative fees or service charges, are not covered.
Exceeding Sub-Limits: Some policies have sub-limits for specific treatments. Claims exceeding these sub-limits may be partially or fully rejected.
Unjustified Hospitalization: Hospitalization primarily for diagnostic or evaluation purposes without required medical necessity can cause claim rejection.
Policy Exclusions for Certain Treatments: Some policies exclude specific treatments like cosmetic surgery, dental treatments, etc.
Pre-Authorization Not Obtained: For certain procedures, pre-authorization from the insurer is required. Failing to get it can cause rejection.
Non-Disclosure of Secondary Insurance: If you have secondary insurance and fail to disclose it, claims can be rejected.
Miscommunication or Misunderstanding of Policy Terms: Lack of clarity or misunderstanding regarding the policy terms by the policyholder can cause rejection.
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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”.