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Common Reasons Why Health Insurance Claims Get Rejected

Health is wealth, as goes the old saying. These golden words start making more sense when the treatment for an ailment makes you feel the pinch. Stressful schedules, sedentary lifestyles, pollution, food adulteration and contamination have made staying healthy a major challenge and therefore, everyone now realizes the importance of being covered by health insurance. But at times, to your utter disbelief, your claim request gets rejected. While not disclosing a pre-existent disease is a major reason behind the rejection, there are also other grounds for the dismissal.

Here are top 5 reasons why claims generally get rejected:

Wrong information: Any discrepancy, be it a sincere mistake while filling the form like a spelling mistake or a genuine attempt to hide information like age, annual income, lifestyle and family health details will lead to not just rejection of the claim but termination of the policy. Often the sum insured is based on annual income and providing false income details just to get a higher sum insured can also lead to rejection of claims.

Pre-existing Illness: Policy holders sometimes buy insurance keeping a future treatment in mind but forget that pre-existing ailments are not covered and attempt to hide the medical details, which can be reason for claim rejection. Most insurance companies do not cover pre-existing diseases such as high blood pressure and so, any medical expenses incurred due to that will not be covered. This is generally done to prevent people from taking insurance just before hospitalization for an existing medical condition.

Not knowing the exclusions: Just like pre-existing ailments, there are other exclusions as well. Policy holders often miss out on reading the terms and conditions that clearly state that an injury caused while being drunk or doing adventurous sports will not be covered. Similarly, there is a waiting period of at least 30 days from the date of the policy before which no claim can be made. If it’s a case of an accident, the waiting period is not applicable, but again, the accident shouldn't have taken place due to intoxication. One must tally the exclusions (usually in fine print) before calling the insurer.

Policy lapse: There have also been cases of people taking a week or a month’s time before renewing the insurance and they have fallen ill during that phase and they have been denied a claim. It is so because the policy lapses on its last day. So, even if one is admitted in the hospital merely a day later, his/her insurance will not work. That’s why it’s important to renew the policy annually before the deadline.  

Not informing the insurer on time: A fatal accident can be a traumatic experience where a person or his/her family members may not immediately remember to inform the policy provider. This mistake could add to their worries. Most health insurance policies clearly mention that the insurer must be informed within 24 (or in some cases 48) hours of hospitalization, otherwise no coverage will be provided. Therefore, it is important to take the policy from a provider who is available 24x7 and responds swiftly. Also, authorize a nominee who can inform the insurer as well as take care of the rest of the paperwork in case the policy holder can’t.

Read about the claim process for HDFC ERGO Health Insurance    

You can also read about 6 Questions about Mediclaim Policy that every Health Insurance Seekers should know

Disclaimer: The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales.


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