Learn to deal with Health insurance claim rejections

When your health insurance claim gets rejected, then you should always look for the errors in the claim form which you have submitted. You can also do rectifications in the claim form by taking the support of a third-party representative along with the accurate documents.

To get a successful claim, it is a must to understand the circumstances under which claim is rejected and what preventive measures can be taken to avoid the same. Know about here the circumstances under which health insurance claim form is rejected:

  • The ailment for which claim is made is not covered under your health insurance plan.
  • When you have not filled the claim form properly.
  • The procedure for which you were asking claim was not required by the insured, medically.
  • The claim has not been filed in the correct time-frame as per the policy.

Learn here the prevention of health insurance claim rejection

The factors to keep in mind about your health insurance policy to avoid rejections are as follows:

  • Always keep the copies of all the documents that you have submitted along with the claim form as a future reference.
  • Make sure that you have gone through every aspect of the policy about the terms and conditions. The most important one is exclusions and deductibles included in your claim policy.
  • Make sure that you submit the claim request 30 days before from the date of hospitalization.
  • You need to provide all your medical records to the TPA. In the case of post-hospitalization, the details of the cost incurred must be submitted within 90 days from the date of hospitalization.
  • Always cross-check the insurance claim form for accuracy. 
  • It is a must to have all the information and proof such as doctor’s prescriptions, etc. to submit or post it to the TPA ( Third Party Representative).

What Needs to Be Done?

Even your claim is rejected, then also insurance company may consider your claim keeping in mind that you can convince the insurer that you are making a genuine claim. But to make this happen, it is essential to understand how you  can  make a successful claim:

Error in your name or policy number: First see your medical insurance claim form which is submitted to the insurance company. The most important thing to check in the form is the name and the policy number. If you find any error in your name or policy number, in that case, you can ask the representative to reopen the case. Along with TPA, the insurer should also aware of the errors.

System error : An insurance claim form is also rejected due to errors in the system, which results in generating insufficient information provided by the claimant. In this case,  the third party representative will find a solution and makes sure that you keep a record of this conversation and document it for future references.

Incorrect documentation: You need to check that all the documents sent along the claim form should not be insufficient or incorrect or even unattested.  In case, you find this problem in your claim form, it can be sorted out by providing correct and attested documentation.

If the medical procedure deemed not required: If the reason for rejection is medical procedure deemed is not necessary, then you are required to take sufficient opinion from the licensed medical practitioners to get a claim successfully.

Further plan of action after gathering all the documents to support your claim

  • You need to send a formal letter along with providing a statement, mentioning all reasons are valid.
  • Attach the correct and attested documents along with the medical opinion of the licensed medical practitioner for claim substantiation.
  • Note, you can make multiple appeals for the claim validation that can be made.
  • If the insurer does not respond to your claim within 30 days, you can approach Ombudsman. This organization helps you in submitting a written complaint at the Office of insurance Ombudsman within 30 days from the health insurer's response.

Hence, make sure you have a valid claim and have sufficient supporting documents