By Okbima 03 Jun 2024

Why Health Insurance Claim Gets Rejected? Know The Actual Reason


If you want to now about Why health insurance claims get rejected? The health insurance claim may get rejected due to incomplete or inaccurate information provided by the policyholder. Health insurance provides coverage for medical expenses to reduce financial burden. A policyholder can get a claim, by submitting relevant documents, such as bills and medical reports, to the insurance company for review and approval. Let’s know in detail why the health insurance claims get rejected.


10 Reasons For Health Insurance Claim Rejections

There are so many reasons for health insurance claim rejection such as incomplete or incorrect information, non-coverage of specific treatments, non-disclosure of pre-existing conditions, etc.,

  1. Incomplete or incorrect information: If the policyholder provides inaccurate or incomplete information while filing the claim, it can cause rejection of the claim. This could include missing documents, incorrect details, or not following the proper procedure.

  2. Non-coverage of specific treatments: Some of the best health insurance plans may have certain exclusions or limitations on coverage for specific treatments or procedures. If the claim is for a treatment that is not covered under the policy, it will be rejected.

  3. Non-disclosure of pre-existing conditions: If the policyholder fails to disclose pre-existing conditions at the time of purchasing the policy or while filing a claim, it can cause rejection of the claim.

  4. Out-of-network provider: If the policyholder gets treatment from a healthcare provider that is not included in their insurance network, the claim may be rejected.

  5. Filing claims after policy expiry: Claims filed after the policy has expired will be rejected. It is important to file claims within the specified time as per the policy terms.

  6. Fraudulent claims: Insurance companies have strict rules to detect and prevent fraudulent claims. If a claim is found to be fraudulent, it will be rejected.

  7. Lack of documentation: Inappropriate or missing supporting documents required for processing the claim can also be rejected.

  8. Policy limitations: Some health insurance policies have limits on the number of claims or the amount that can be claimed for certain treatments. Exceeding these limits can cause claim rejection.

  9. Waiting period: Certain policies have a waiting period in health insurance before certain types of claims can be made. If a claim is made during this waiting period, it may be rejected.

  10. Policy exclusions or restrictions: Every health insurance policy has specific exclusions and restrictions that the policyholder must follow. Not following these restrictions can cause claim rejection.


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Impact Of Health Insurance Claim Rejections

Health insurance claim rejections in India can have a significant impact on individuals and families such as financial burdens, delayed treatment, trust issues, etc.

  • Financial burden: When a health insurance claim is rejected, individuals may have to bear the entire cost of medical treatment, which can be a significant financial burden, especially in case of high medical expenses.

  • Delayed treatment: Rejected claims may cause delays in receiving necessary medical treatment, which can impact the health condition of the individual and can cause further complications.

  • Trust issues: If the insurance company keeps denying claims, customers may stop trusting them. This can make customers unhappy and hesitant to keep using their insurance.

  • Stress and frustration: Dealing with rejected health insurance claims can be a stressful and frustrating experience for individuals and their families that can cause anxiety and worry about how to pay for medical expenses.

  • Limited access to healthcare: Individuals who are unable to afford medical treatment due to rejected claims may have to limit their access to healthcare, which can have long-term consequences on their health and well-being.


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Ways To Avoid Health Insurance Claim Rejections

There are many ways you can use to avoid health insurance claim rejections such as filling out all information accurately, keeping copies of all documents, understanding your policy, submitting claims on time, etc.

  • Fill out all information accurately: Ensure that all information provided in the health insurance claim form is accurate and complete. This includes details about medical treatment received, diagnosis codes, and bills.

  • Keep copies of all documents: Make sure to keep copies of all relevant documents such as medical bills, prescriptions, and diagnostic reports.

  • Understand your policy: Understand the terms and conditions of your health insurance policy. This will help you understand what is covered and what is not, making it easier to submit valid claims.

  • Submit claims on time: Make sure to submit your health insurance claims within the mentioned time in your policy. Late submissions can cause claim rejections.

  • Take pre-authorization when required: Some insurance policies need pre-authorization before undergoing certain medical procedures or treatments. Make sure to get pre-authorization if required to avoid claim rejections.

  • Seek network hospitals: If your policy has tie-ups with specific hospitals or healthcare providers, try to get treatment from these network providers. This can help in smoother claim processing.

  • Consult with the insurance company: If you are unsure about any aspect of your claim or need help with the submission process, do not hesitate to consult with the insurance company. They can provide guidance and ensure that your claim is processed smoothly.


Read More:

Health Insurance For New Born Baby: Benefits, Types & Required Documents

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

Does Health Insurance Cover Therapy?

Grace Period In Health Insurance: Meaning, Benefits

Government Health Insurance Schemes for Senior Citizens 2024



In conclusion, health insurance claim rejections can be a challenging and stressful experience for policyholders. It is important to understand the reasons for claim rejections, such as incomplete or inaccurate information, policy limitations, non-disclosure of pre-existing conditions, and more. 

By taking proactive steps to avoid claim rejections, such as filling out information accurately, keeping copies of all documents, understanding the policy terms, and submitting claims on time, individuals can reduce the risk of claim rejections. For expert guidance, you can contact “Our Experts”.

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