Why insurance claims get rejected?

Health insurance in India is more than just a policy, it’s a safety net that ensures you and your family can access quality healthcare without financial stress.

Understanding how it works, particularly the pre-existing condition clause, is crucial, as this clause can lead to claim rejections when coverage is needed most.

Let’s explore how this clause impacts your policy with real-life examples.

How does claim rejection work?

In a notable case reported by the Economic Times, a widow successfully secured Rs 28 lakhs in damages after her husband’s health insurance claim was initially denied.

The insurance company had rejected the claim, citing a pre-existing condition as the reason.

However, the court ruled in the widow’s favor, stating that the death was not caused by any concealed or undisclosed pre-existing condition at the time the policy was issued. As a result, the insurance company could not legally deny the claim.

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Common reasons for claims denial

• Non-disclosure of Pre-existing Conditions: If the insured person fails to disclose any pre-existing medical conditions at the time of purchasing the policy, the insurance company might reject the claim if the condition directly contributes to the health issue for which the claim is made.
• Claims During the Waiting Period: Many policies have a waiting period during which certain treatments or conditions are not covered. If a claim is made for treatment within this period, the insurer can deny it.
• Incomplete or Incorrect Documentation: Submitting incomplete or incorrect paperwork can lead to claim rejection. It’s crucial to provide all required documents accurately.
• Treatments Not Covered Under the Policy: If the treatment or condition for which the claim is made is not covered under the policy terms, the insurance company is within its rights to reject the claim.

What are pre-existing clauses?

Pre-existing conditions refer to any medical condition or illness that a person has before they obtain health insurance coverage. These conditions are often documented by medical records, and insurers usually impose specific clauses related to them.

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How do they work?

When you apply for health insurance, insurers usually ask for your medical history. If you have a pre-existing condition like diabetes, hypertension, or a heart condition, the insurer may either

• Impose a waiting period during which they will not cover expenses related to the pre-existing condition
• Increase the premium to offset the risk
• Exclude coverage for the pre-existing condition altogether

Example: Mr. Sharma, who has diabetes, applies for health insurance. His policy might have a waiting period of 2-4 years for diabetes related treatments. This means if he incurs medical expenses due to diabetes within this period, the insurance will not cover it.

How to avoid claim rejection?

• Disclosing all medical history accurately when applying for insurance
• Understanding the terms and conditions of your policy, especially exclusions and waiting periods
• Ensuring all documentation is complete and correct when filing a claim

According to Policy Bazaar, out of the total claims rejected, 75% rejections are caused due to limited understanding of health policy and undisclosed pre-existing diseases. This highlights the need to have a better understanding of health policies to avoid claim rejections.

Let’s understand this with an example

Imagine Mrs. Singh, a 45 year old woman with a history of hypertension. She buys a health insurance policy.

Here’s how her experience might unfold:

This scenario demonstrates how understanding your policy and ensuring accurate documentation can influence claim outcomes.

Final takeaway

Health insurance is essential for financial protection against medical emergencies. Understanding pre-existing clauses and the claim process can prevent unpleasant surprises.

By disclosing medical history accurately, keeping thorough records, and understanding policy terms, you can navigate the health insurance landscape with confidence.

Remember, health insurance is not just a piece of paper, it is your shield against unforeseen medical expenses. Make sure you know how to wield it effectively!

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Summary

To make your life easier, we have summarised the above Read here. Hope you enjoyed it!

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