Navigating Health Insurance Claims: A Guide to Avoiding Pitfalls
MAS Team | 24 November 2023
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Health insurance stands as a financial safety net during medical emergencies, yet it's disheartening that a significant 75% of health insurance claims in India face rejection, according to Policybazaar. This raises a crucial question about the need for policyholders to gain a deeper understanding of health policies to avoid common pitfalls leading to claim denials.
 
Reasons Behind Claim Rejections: A Deeper Dive
Several factors contribute to the high rate of claim rejections:
  • Early Filing: Over 18% of rejections result from filing claims before the waiting period is over.
  • Coverage Gaps: A quarter of rejections (16% for ailments not covered and 9% for non-payable OPD and daycare claims) occur due to misunderstandings about coverage.
  • Incorrect Filings: 4.5% of claims face rejection due to errors in filing.
  • Limit Exhaustion: Although a smaller percentage, 2.12% of claims get rejected due to exceeding policy limits.
  • Non-Disclosure: A significant 25% of claims are rejected because policyholders fail to disclose pre-existing conditions.
  • Unanswered Queries: Over 16% of rejections occur due to unsubmitted query reverts.
  • Unjustified Hospitalization: 4.86% of claims are rejected for hospitalizations not meeting policy criteria.
  • Sum Insured Impact: Notably, the sum insured range plays a significant role, with 53% of claims rejected in the Rs5 lakh category.
 
Tips to Avoid Health Insurance Claim Rejections
To ensure a smooth claim process, consider the following strategies:
  • Verify Coverage: Understand what your policy covers, including pre-authorization requirements.
  • Provide Accurate Information: Double-check personal details, medical codes, and treatment descriptions on the claim form.
  • Keep Documentation: Maintain records of all medical bills, prescriptions, and invoices.
  • Submit Claims Promptly: File claims as soon as possible to meet insurer deadlines.
  • Follow Procedures: Understand your insurer's specific claim filing requirements.
  • Seek Pre-Authorization: Obtain necessary approvals for treatments or procedures requiring pre-authorization.
  • Review Exclusions: Familiarize yourself with policy exclusions and limitations.
  • Communicate Effectively: Stay in touch with healthcare providers to align treatments with policy coverage.
  • Review Before Submission: Thoroughly review all claim details for accuracy before submission.
  • Be Persistent: In case of rejection, study reasons, communicate with your insurer, and appeal if necessary.
 
By adopting these proactive measures, policyholders can navigate the complex landscape of health insurance claims, minimizing the risk of rejections and ensuring a more successful claims experience. Stay informed, communicate effectively, and maintain meticulous documentation to safeguard your financial well-being in times of need.