Health Insurance

Do You Know Why Health Insurance Claim Gets Denied?

An average human is in a dilemma whether to feel happy for the increased life expectancy or to feel sad for an increased longevity with health ailments as part of it. Though technology has made human…

An average human is in a dilemma whether to feel happy for the increased life expectancy or to feel sad for an increased longevity with health ailments as part of it. Though technology has made human’s life simple, it is also an undeniable fact that this has led to lack of physical activity. Adding to it, quick and junk foods lacking nutritive elements due to busy lifestyles have taken a toll on our health especially in the past 10 years. This led to the rise of health screenings in regular intervals even for the middle- income group. The rise in the number of hospitals and health insurance companies are classic examples of how the health conditions of an average individual are prevalent globally. Although number of hospitals have increased, inflation has kept the health care charges soaring thereby preventing a common man to get quality health care. In such a scenario, a health insurance policy acts as a boon in the life of an individual.

But is it enough to just buy a policy? Does a simple health insurance policy suffice every health need of yours? Is your insurer standing by you in times of need? The answer may not be promising all the times. Yes! You read that right!! There are times when your health insurance policy does not aid you. In spite of sincere efforts of the insurer to pass your claim, they may have compelling reasons to put your claim down! But, do you know why your health insurance claim gets denied?

Reasons for Claim Denial:

Concealing or Wrong Show of Material Facts:

It is not the insurer who is responsible for the denial of your claim at all times. Sometimes, it can be you too! Although it sounds weird, that is the fact! An insurance policy is implicitly issued on the notion that the proposer, the policy buyer, has stated only facts in the proposal form and it applies to all the insurance policies ever bought and sold that they are in adherence with faith and loyalty.

Under writing is performed on the basis of submitted facts and the insurance company analyzes the risk of the prospective policy holder. If the prospective policy buyer hides crucial facts or lies about an underlying medical condition that he/she is suffering from, it is a potential fraudulence.

In such cases, at the claim scenario, if the insurer finds a mismatch between the current ailment and submission of facts about underlying medical condition, the insurer will classify it as a misrepresentation of facts. At such an instance, the insurance company has all the right to deny your claim. So, know why your health insurance claim gets denied and find the ways to undo it.

Wrong Claim Procedures:

Buying an insurance policy means you get into a contract with the insurance company that you will follow certain procedures if you have to make a claim. Those procedures may involve

  1. Informing the insurance company about an emergency
  2. Getting treatment in a hospital recognized by the insurance company
  3. Filling up the claim form as per the norms
  4. Submission of all the relevant medical bills
  5. Submission of investigative reports

If these steps are properly followed, you are in the right direction of helping the insurance company process your claim. If not, there is a high probability that your health insurance claim gets denied.

Claims on expired policies:

It is necessary that you should keep paying the premiums on time to keep the policy going. If you discontinue paying premiums, your policy may get expired and you may end up getting a denial on your claims.

Claims for permanent exclusions:

Certain conditions are excluded from the insurance coverage and this is an agreement at the time of buying the policy itself. If you do not know the terms of your policy and file a claim, it may get rejected.

Ways to avoid claim rejection:

  • Correct disclosure of facts and submission of proofs of existing medical condition
  • Informing the insurance company about the hospitalization beforehand in case of planned hospitalizations
  • Seeking admittance to a hospital in the network of the insurer
  • Submission of complete medical documents and bills
  • Following right claim procedures
  • Regular payment of premiums

No insurance company wants to reject their clients’ claims as it would be a breach of trust.  However, it is also essential for them to process the claim in a righteous way. So, assisting the insurance company in processing your claim in a right manner may solve it all. Now you know why your health insurance claim gets denied and the ways to avoid a claim rejection. So, it is mandatory to follow the guidelines set by your insurer to get financial aid in times of need!!

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