Health Insurance Claim Rejection Reasons: Why Your Health Insurance Claim Might Be Rejected

10 min read Posted on 10 Jul 2025

Health insurance provides financial support during medical emergencies. However, claims are sometimes denied due to common oversights, not just major policy violations. Understanding the health insurance claim rejection reasons can save you from unnecessary stress and financial burden.

Whether it's a pre-existing disease, non-disclosure, violation of waiting periods, or incomplete documentation, knowing what can go wrong helps you prevent it. This article will explain the common causes ofclaim denial with real-life examples and simple solutions to be informed and protected.

Common Health Insurance Claim Rejection Reasons

The following are common and significant reasons for health insurance claim rejection.

1. Non-Disclosure of Pre-Existing Diseases

Many claims are denied because people don’t reveal they have had any pre-existing diseases. You have to provide a list of any illnesses you already have when you buy a health insurance policy; these are called pre-existing diseases (PEDs).

Illnesses you could note include diabetes, asthma, thyroid issues or the operation you had years ago. If you didn’t mention your pre-existing condition when you took out the policy, and your insurer learns about it during a claim, they may deny your claim.

Example: Rahul, a 35-year-old, did not disclose that he had mild hypertension when buying insurance. Two years later, he was hospitalised due to a heart issue. His claim was denied because his insurer found out about the undisclosed hypertension during the claim process.

How to avoid it: Disclose all medical history during policy purchase, even minor conditions.

2. Violation of the Waiting Period

Every health insurance policy has something called a waiting period. This is the time you must wait before you can claim for certain illnesses.

An initial 30-day waiting period for all illnesses except accidents
1 to 2 years for specific conditions like cataract, hernia, or joint replacements
Up to 4 years for pre-existing conditions

f you raise a claim within this waiting period, it is likely to be rejected.

Example:Priya bought health insurance and, just six months later, underwent surgery for gallstones. Her claim was denied because her policy had a 2-year waiting period for such procedures.

How to avoid it: Understand the waiting period details mentioned in your policy beforehand.

3. Incomplete or Incorrect Documentation

A lot of health insurance claims get delayed or even get rejected just because the paperwork is not done correctly. Maybe a bill is missing, the discharge summary has errors, the doctor’s prescription doesn’t match the treatment, or ID proof wasn’t submitted properly.

Such cases are categorised as incomplete documentation claims.

Example: Aman sent scanned copies of his hospital bills in order to get a claim, but forgot to include the signed discharge summary. His claim got stuck for weeks.

How to avoid it: Maintain a checklist of required documents, and ensure all are properly submitted. Wherever originals or attested copies are required, make sure you submit them. And if you are ever confused, just ask RenewBuy’s team or your insurance company. Better safe than sorry.

4. Claim Raised for an Excluded Illness

There is a list of exclusions in every policy, exclusions like medical conditions or treatments the insurer does not cover. Common exclusions include cosmetic surgeries, dental treatments (unless it is injury-related), and fertility procedures.

If you file a claim for something that is clearly excluded, it will definitely get rejected.

For example, Shreya decided to get a nose reshaping surgery and tried to claim it under her health plan. The claim was rejected as cosmetic procedures were not included in her policy.

How to avoid it: Go through your policy document carefully, especially the exclusion section. Review policy exclusions or consult your insurer for clarification.

5. Incorrect Hospitalisation or OPD Confusion

Health insurance mostly covers hospitalisation, which means that you get a claim when you are admitted for at least 24 hours. However, if you only visit the doctor and get a prescription (also called OPD care), that may not be covered unless your plan includes OPD add-ons.will be partially reimbursed, not fully.

Submitting OPD bills under plans that only cover hospitalisation will result in rejection.

For example, Neha went to a dermatologist to get treatment for her skin issues. She paid ₹ 4,000 and then tried to claim it. Her plan clearly did not include OPD, so the claim was denied.

How to avoid it: Carefully look at what your coverage plan includes- OPD, daycare, or full hospitalisation. RenewBuy can help you choose plans that better fit your needs.

6. Missed Premium Payments Leading to Policy Lapse

If your policy lapses, meaning you did not renew it on time. In that case, any claim raised during that period will be rejected. Even a brief lapse in coverage can void continuity benefits.

For example, Ravi missed renewing his policy by just three days. That weekend, he met with an accident and was hospitalised. Sadly, he was not given any claim as the policy had already lapsed.

How to avoid it: Set calendar reminders or go for auto-debit options. With RenewBuy, you get renewal alerts and reminders well in advance.

7. Delay in Claim Intimation

Many insurers ask you to inform them within a time frame of 24 to 48 hours of hospitalisation, especially for emergency claims. Failing to do so can result in rejection of the claim or reduced reimbursement.

For example, Ananya got hospitalised for dengue, but informed her insurer after she got discharged. In this case, her claim will be partially reimbursed, not fully.

How to avoid it: Notify the insurer within the specified period to avoid partial or full rejection.

8. Incorrect Claim Type

There are two types of claims: cashless claims, where the insurer settles the bill directly with the hospital, and reimbursement claims, where you pay the amount first and then get a claim later.

If you go to a non-network hospital (a hospital not included in partner hospitals in your policy) expecting a cashless facility, it won’t work. This results in claim denial if cashless treatment is expected at a non-network hospital.

For example, Sanjay did not read his policy clauses carefully and thought all hospitals accepted cashless claims. He got treatment at a non-network hospital and paid Rs. 80,000. Later, when he submitted a cashless request. It got rejected.

How to avoid it: Check the list of network hospitals before getting a treatment on RenewBuy’s platform and before choosing a hospital.

Health Insurance Claim Process

How RenewBuy Helps You Avoid Claim Rejections

RenewBuy aims to simplify health insurance by reducing claim-related confusion. Here is how it makes the process simpler, smarter, and safer:

Smart Comparisons: Makes choosing insurance for medical history, needs, and budget easier. With this, you avoid ending up with insurance that’s not sufficient.
POSP Support:Trained POSP (Point of Sales Persons) steps in to assist with filing your claim, completing paperwork, and resolving disputes as necessary.
Claim Assistance: There are tools and support available to guide you each step of the way when you make a claim.

Conclusion

Usually, health insurance claims are denied because people don’t pay attention to their policy or fail to follow its rules. The main thing is to be aware of what’s going on in your mind. By understanding and avoiding the common reasons for claim denial, like non-disclosure of medical history, policy lapses, documentation errors, or waiting period violations, your claim process will be much simpler when you need care.

Disclaimer: The content published in this article is intended solely for the readers' informational purposes and should not be relied upon for personal, medical, legal, or financial decisions. It is advisable to seek advice from a qualified professional regarding specific concerns. The details provided regarding the plan are for reference purposes only. Please visit the insurer’s website for the latest updates on the plan. The company does not guarantee suitability, reliability, timeliness, or accuracy of the information, services, or any other aspects mentioned in this regard for any purpose. We do not endorse any insurance company or insurance product provided by any insurer.