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Reasons Why Your Health Insurance Claim Can Be Denied

health insurance coverageIn this time of rising medical inflation, investing in a medical insurance policy has become the need of the hour. The benefits of a health care plan indeed out weigh the cost. Many individuals, therefore, invest in a health care policy to enjoy financial protection in case of a medical emergency.

You may either opt for a reimbursement of the medical expenses incurred by you, or you may file a cashless claim. Though the procedure for filing a claim is quick and hassle-free, sometimes it may get rejected.

Following are six major reasons why your health insurance claim may be denied.

1. Providing inaccurate or incomplete details

One of the reasons for denial of the claim is a failure to furnish complete or accurate details. These details may pertain to your health condition, pre-existing conditions, or nature of employment, among others. Since these factors are crucial in helping the insurance provider to determine your eligibility and premium, they may deny the claim if they find out that crucial information has been withheld or if facts have been misrepresented.

2. Seeking claims for exclusions

Most medical health insurance plans come with a list of diseases and ailments that are beyond the scope of coverage. Making a claim for any conditions or ailments in the exclusion list will fail to qualify for coverage and hence the claim will be rejected.

3. Making a claim during the waiting period

Waiting period refers to the specified time frame that you must wait for, before beginning to enjoy benefits of the policy. This is the period during which pre-specified illnesses are not covered by your policy. Hence, making any health insurance claim during the waiting period will result in it being rejected.

4. Admission to a non-network hospital

Insurance companies have a network list of hospitals. In order to avail of a cashless facility, it is imperative to get admitted at any of the hospitals in the insurer’s network. The insurance provider may reject your cashless claim in an event that you are admitted to a non-network hospital. In such a case, however, you may seek reimbursement of the hospital expenses incurred by you. You may submit the original bills, medical reports, and fill the claim form while seeking reimbursement.

5. Claims made on lapsed policies

Your policy may stand lapsed in case you have failed to make premium payment before the due date. Making a claim once your policy has lapsed will mostly result in denial of the filed claims. It is, therefore, necessary to make timely payment of your medical health insurance premiums in order to enjoy uninterrupted benefits of your health policy.

6. Failure to notify the insurer within the stipulated time frame

Your medical health insurance policy states the period within which you must inform the insurance provider of your hospitalization. If the claim has not been brought to the notice of the insurer within the time frame stipulated in the terms and conditions of the policy document, the insurance claim will be rejected. You may, therefore, submit the insurance claim request within the time frame. You may also submit the original hospital bills as well as post-hospitalization expenses if any.

A medical health insurance claim denial may threaten your financial security and the ability to receive medical care. It is, therefore, necessary to identify the possible causes of rejection. Once you are well aware of the possible causes of claim denial, you may follow the guidelines to ensure that your claims are honored.

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