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Was your Health Insurance Claim Rejected. How to Prevent it? Research Team | Posted On Friday, May 18,2018, 07:05 PM

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Was your Health Insurance Claim Rejected. How to Prevent it?



What after you avail a Health Insurance plan? You pay premiums, renew your policy and enhance it as and when the need arises. But what if the insurer rejects your claim? Now, you might wonder why buy a health insurance policy at all? But it is your responsibility to see that your claim is settled by taking every measure possible towards it. It’s important that you read the fine print carefully.
If you fail to do so chances are that you may invite trouble. Want to know more about Health Insurance? We at will make it easy for you. Just give us a missed call on 022 6181 6111 to explore our unique Free Advisory Service. is not a seller of any financial products. We only provide FREE financial advice/education to ensure that you are not misguided while buying any kind of financial products.

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Was your Health Insurance Claim Rejected | How to Prevent it?

There are many other grounds on which your claim may be rejected:

The ailment is not covered under your Health Insurance policy.

  • The claim form has not been filled properly.
  • Submission of incomplete or inadequate documents.
  • You miss the time-frame, as per the policy, to file or apply for the claim.
  • The insurer thinks a particular medical procedure was unnecessary.

How can you prevent a Health Insurance claim rejection?

A claim rejection can be prevented by taking these measures:

Make and retain copies of all the documents that you submit along with the claim form to the TPA. This will serve as a future reference.

  • Thoroughly read and understand policy wordings and terms and conditions like exclusions, deductibles and claim process. Also, go through the benefits of your policy.
  • Submit the claim request well within the time-frame as per your policy.
  • Furnish all medical records relating to pre-hospitalization, hospitalization and post-hospitalization to the TPA.
  • Double-check the claim form. Also, keep multiple forms on hand in case you need to fill it again before submission.
  • Gather all the required information and proofs like doctor’s prescriptions, hospitalization bills, etc. and submit it to the TPA.
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What needs to be done next?

If you are able to convince the insurer that your claim is genuine, they may reconsider your claim. The wisest thing to do in such cases is to find out why your claim was rejected in the first place so that you don’t repeat the same mistake. Once you know the reason you have to:

Fill and verify the insurance claim form to be submitted to the insurer. Be mindful of names and policy number of the policy. The TPA and insurer must be made aware of any error or blunder in reporting these in the claim form so that the case can be reopened.

  • Errors in the system may also lead to rejection of claims. This happens when you provide insufficient details. In such cases, approach the TPA representative who will assist you. It is advisable that you document and record this conversation for future reference.
  • Check the documents to be sent with sent with the claim form before submitting. Also, make sure they are attested.
  • In case your claim is rejected due to a medical procedure which the insurer thinks is unnecessary, you should get sufficient opinions of licensed medical practitioners.
Finally, after collecting all the documents to support your claim:

Send a formal letter stating the reasons for your claim being genuine.

  • Attach all the necessary documents along with the medical opinion of the licensed medical practitioner.
  • You can make multiple appeals for the claim validation.
  • The insurer must respond in 30 days. If they fail to do so, you can approach the Ombudsman who allows you to lodge or file a written complaint at the Office of insurance Ombudsman.
  • If this doesn’t help, you might have to seek legal aid. Be Wise, Get Rich.

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