How to handle Health Insurance Claim rejection

Here’s How to handle Health Insurance Claim rejection:

How to handle Health Insurance Claim rejectionIn matters of health insurance, you cannot take chances. Especially; when it comes to health insurance claim settlement. The latest Public Disclosure 2015-16 data of health insurers reveals that out of 100 claims, only 89% to 94% are settled. It means that you can be one among the ten persons whose health insurance claim are getting rejected.

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The reason for health insurance claim rejection could have been avoidable. Had you been vigilant at the time of buying the policy?

Intrigued huh…

In most of the cases, primary negligence or recklessness in disclosing material information may lead to claims repudiation. At this juncture, you need to understand the first principle guiding all kinds of the insurance contract.

It’s called the principle of “Utmost Good Faith” or “Uberrimae Fidei”. It says that the contract should be entered into on mutual trust and good faith. There needs to be full disclosure of material information between the insurer and the proposer.

Got too much technical!

Let me simplify it.

When you are buying health insurance, it’s the agent’s responsibility to disclose policy terms and condition. In the same manner, you too are expected to do the same. You need to reveal all the relevant information regarding your health in the proposal form. It covers everything from your general health conditions to the occupation.

All the information given by you would be used to determine the premium amount. Any discrepancy or non-disclosure may amount to a claim rejection in future. It’s like you’re the insurer refuses to settle the claim on the spot. Sometimes, it may take as long as 3 months to get reimbursed. At other times, it may not be resolved at all.

So, getting your claims rejected is an appalling thing. After all, it invalidates the whole premise of purchasing health insurance. You would be surprised to know that a little more care from your side may prevent this inconvenience altogether.

Hence, it becomes indispensable to look into the reasons which lead to a health insurance claim repudiation:

How to handle Health Insurance Claim rejection

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1. Negligence while filling proposal form

You are solely accountable for all the information that’s transmitted to the insurer via proposal form. That would constitute the basis for all kind of future interactions and exchanges. Letting your agent or broker fill the proposal form happens to be your biggest mistakes. The agent doesn’t know precisely your credentials. So, he may fill in wrong details in the form. It may lead to a misrepresentation which the insurer can challenge in the court of law.

It’s imperative that you fill the proposal form accurately in your handwriting.

2. Hiding Pre-existing diseases

Pre-existing diseases are the health conditions/illnesses that you are suffering from at the time of buying health insurance. Usually, insurers cover these ailments after a waiting period of 3 or 4 years. If you are planning to hide any pre-existing illness to avoid waiting period, then think again. Your claim can be repudiated by the insurer on the basis of non-disclosure of pre-existing diseases.

Always reveal the actual state of health before the insurer. Undergo medical tests prescribed by the insurer. Submit the detailed report to the insurer.

3. Not reading policy terms and conditions

Policy terms and conditions guide the contractual relationship between you and the insurer. So, these are meant to be taken seriously. Trusting your agent/broker is ok. But you can’t finalise your buying decision solely on the word-of-mouth. Read and understand the policy terms and conditions carefully; especially the inclusions & exclusions.

It might happen that even after receiving the policy document, you are confused about your decision. You need not worry. You can change your decision within the “Free Look Period”. It’s a period of 15 days within which you may step out of the insurance contract. Just intimate the insurer in writing. Your premium would be refunded after making a few adjustments.

Also read: Top up & super top up health insurance policies

4. Incurring uncovered medical expenditures

There are instances when you undergo medical procedures as preventive measures. At other times, the hospital authorities may project these as unavoidable. But remember one thing; your health insurer is not going to reimburse all of it. Based on your medical history, your insurer would have prepared a list of relevant medical procedures.

If your claim doesn’t fall in line with the specifications, then he won’t be responsible for settling it. Hence, don’t take medical tests just for the sake of it. Ensure that it’s entirely relevant and necessary for your well-being.

5. Technical Irregularities

Often you may miss out on technical accuracies which may cause claim rejection. You might have filled the wrong form or not submitted any important hospital bill. Sometimes, if you get treated in a non-network hospital, your cashless claims might be rejected. Non-network hospitals are those that aren’t empanelled by the health insurer. Treatment in one of these won’t qualify you for a claim.

So, the next time when you are going for claims keeps your documentation proper and complete.

What should be done in case of Health Insurance Claim Rejection

Insurers are bound to admit claims under contractual obligations. However, they may refuse to settle claims in case of technical irregularities or other reasons.

You need not lose hope in the event of health insurance claim rejection. You may pursue grievance redressal in the following manner:

1. Approach grievance redressal officer of insurer

Every health insurer has appointed a Grievance Redressal Officer to look into policyholder complaints. Give a written complaint with all the supporting documents. These may include medical reports, consultation fees, letter of recommendation for hospitalisation, final bills, lab reports, medicine bills, discharge summary, receipts, etc. You may support your claim with medical opinion of the doctor in writing.

Upon submission of the complaint, remember to collect written acknowledgement of your complaint with the date. If you are dissatisfied with insurer’s response, then Grievance Redressal Cell of IRDA.

2. Grievance Redressal Cell of IRDA

When your health insurer can’t provide you satisfactory solutions, IRDA helps you in following ways:

a. Approach Grievance Redressal Cell of IRDA. You may call on toll-free number 155255 (or) 1800 4254 732. Or you may send an e-mail to complaints@irda.gov.in, OR

b. You may register your complaint on igms.irda.gov.in (Integrated Grievance Management System)., OR

c. Fill and send Complaint Registration Form. Attach relevant documents and post it to consumer affairs department of IRDA.

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3. Approach Insurance Ombudsman

If you are dissatisfied with the decision of Grievance Redressal Cell of IRDA, then approach insurance ombudsman. It provides for an out of court settlement of your complaints. You can contact ombudsman having jurisdiction over the office of your health insurer. You may lodge the complaint in writing and attach the supporting documents.

There are some restrictions to this. The health insurance claim amount can’t exceed Rs 20 lakh. The complaint should be lodged within 1 year of claim rejection by the insurer.

In the case of dissatisfaction with ombudsman decision, you may approach consumer forum as the final resort.

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