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5 Reasons Your Health Insurance Claims Could Get Rejected


Health insurance policies ensure that you do not have to worry about medical bills in case of hospitalization. But the moment of truth comes when you actually file a claim. If your claim is rejected, you may be caught off guard and may have to burn your savings instead. This could be disastrous given the rapidly rising medical expenses. But you can easily avoid such a scenario if you are aware of the typical reasons that lead to such rejections. Listed here are the top 5 things you should look out for.

Pre-existing illnesses

Most health insurance policies do not cover pre-existing illnesses from the day the cover starts. Typically, such illnesses and ailments are covered after a waiting period. This waiting period varies from policy to policy and may even be different for different illnesses. You should refer to your policy wordings to check the exact waiting period. If you file a claim for expenses towards treatment or management of such illnesses before the waiting period elapses – the claim is bound to be rejected.

Delay in filing a claim

Most health insurance policies require the insured to inform the insurer of any expenses within a stipulated time period. This is to avoid any fraudulent claims. Typically, in case of emergency hospitalization you or a representative needs to intimate the insurer within 24 hours of hospitalization. For planned hospitalization, most policies require you to inform them of the same at least a week in advance. Missing these deadlines could result in a claim being rejected.

Claim for excluded expenses

Not all medical expenses are covered by all health insurance policies. Some expenses may also have a cap on the amount that can be claimed. For example, almost all health insurance policies exclude conditions arising from alcohol or drug abuse and self-inflicted injuries. If the claim is traceable, directly or indirectly, to a cause that is excluded from coverage – it will be rejected.

Elapsed policy

You need to renew your health insurance policy annually. If you miss renewing the policy on time, you may not get a continuous cover. If you file for a claim for expenses incurred while the policy was not in force, the claim will be rejected. Therefore, make sure that you do not miss your policy renewal date as even a single day without the cover could prove costly.

Misrepresentation or non-disclosure of facts

The insurer issues a health insurance policy based on disclosures you make. These are checked only when you file for a claim. If it turns out that some of the representations you had made during policy enrollment were wrong, your claim will be rejected. For example, if you miss disclosing family history of a disease and the insurer discovers the same at the time of claim verification – the insurer is within his rights to reject the claim.

The best way to avoid surprises when filing health insurance claims is to read the policy terms and conditions carefully, and be familiar with all the exclusions mentioned in them. Equally, be honest about pre-existing conditions and share your medical history with the insurer without any reservations.

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