Having health insurance does not guarantee that all claims will be approved. Many claims get rejected due to avoidable mistakes, lack of documentation, or policy exclusions.

In this guide, we will break down:

1. Why claims get rejected
2. How to avoid common pitfalls
3. Steps to take if your claim is denied

1. Why Do Health Insurance Claims Get Rejected?

1. Incorrect or Missing Information

• Even small mistakes in your claim form (wrong name, policy number, date of birth, etc.) can lead to rejection.
• Missing documents, like doctor’s prescription, discharge summary, or bills, can also result in denial.

How to Avoid This?

• Double-check all entries before submitting the form.
• Ensure all required documents are included.

2. Policy Lapse – Premium Not Paid on Time

• If your policy is inactive due to non-payment of premiums, your claim will be rejected.
• Insurance companies do not cover claims for policies that have lapsed.

How to Avoid This?

• Set reminders for premium payments.
• Opt for auto-debit or ECS for hassle-free payments.

3. Claiming for a Treatment Not Covered by Your Policy

• Many policies exclude specific treatments such as:
• Cosmetic surgeries
• Dental treatments
• Alternative therapies (unless specifically covered)
• Maternity benefits (unless included)

How to Avoid This?

• Read the list of exclusions in your policy carefully.
• Confirm with your insurer before undergoing treatment.

4. Pre-Existing Disease Waiting Period

• If you have a pre-existing condition (like diabetes, hypertension, etc.), most insurers apply a waiting period (2-4 years) before covering expenses related to it.
• If you claim for a pre-existing disease during this period, your claim will be denied.

How to Avoid This?

• Check your policy’s waiting period for pre-existing diseases.
• Choose policies with lower waiting periods if you have medical conditions.

5. Claiming for Non-Medical Expenses

• Some hospital expenses are not covered by insurers, such as:
• Service charges, registration fees
• Disposable gloves, syringes
• Food & toiletries in hospitals
• Attendant charges

How to Avoid This?

• Know what your policy covers.
• Ask the hospital to separate medical & non-medical charges.

6. Treatment at a Non-Network Hospital

• Cashless claims only work at network hospitals (hospitals that have tie-ups with your insurer).
• If you choose a non-network hospital, you’ll need to pay upfront and apply for reimbursement, which may be denied.

How to Avoid This?

• Always choose a hospital from your insurer’s cashless network.
• Check the insurer’s network hospital list before getting treatment.

7. Lack of Pre-Authorization (For Planned Treatments)

• For planned surgeries like knee replacement or heart surgery, you must get pre-authorization from the insurer before hospitalization.
• If you don’t, your claim may get delayed or rejected.

How to Avoid This?

• For planned treatments, get pre-authorization 48-72 hours before admission.
• For emergencies, notify the insurer within 24 hours of hospitalization.

8. Delay in Submitting the Claim

• Most insurers require claims to be submitted within a specific time limit (typically 7-30 days after discharge).
• If you miss the deadline, the claim may be denied.

How to Avoid This?

• Submit your claim immediately after hospitalization.
• Keep a checklist of required documents to avoid delays.

9. "Not Medically Necessary" Treatment

• Some claims are rejected if the insurer believes the treatment was not necessary.
• For example, if you get hospitalized for a minor condition that could be treated with OPD care, your insurer may reject the claim.

How to Avoid This?

• Ensure your doctor provides a strong medical justification for hospitalization.
• Attach all relevant test reports and prescriptions.

2. What to Do If Your Claim Is Rejected?

Step 1: Find Out the Reason for Rejection

• Contact your insurer immediately and ask for a detailed explanation.

Step 2: Review Your Policy

• Check if your claim was genuinely not covered or if it was rejected due to a mistake.

Step 3: Rectify the Issue and Resubmit

• If it was rejected due to missing documents, submit them and request reconsideration.

Step 4: File a Claim Appeal

• If your claim was wrongly denied, file an appeal with supporting medical documents.

Step 5: Escalate the Matter to the Insurance Ombudsman

• If the insurer refuses to process a valid claim, escalate the issue to the IRDAI Insurance Ombudsman.

3. How to Ensure a Smooth Claim Process? (Final Tips)

• Check your policy coverage & exclusions BEFORE treatment.
• Use network hospitals for cashless claims.
• Get pre-authorization for planned treatments.
• Submit all required documents on time.
• Keep all hospital bills, prescriptions, and reports safe.
• Pay your premiums on time to avoid policy lapses.

5. Final Takeaways

• Health insurance claims can get rejected for avoidable mistakes.
• Always check your policy’s inclusions, exclusions, and requirements.
• Use network hospitals, keep documents ready, and get pre-approvals when needed.
• If your claim is denied unfairly, escalate it with an appeal!

Bottom Line: Stay informed, follow the right process, and avoid claim rejection hassles!