Why Your Health Insurance Can Be Denied?

Technical development has provided advanced medical treatments for several illnesses. However, such treatments have increased the cost of advanced healthcare. As a result, you may not always be able to afford the best treatment due to lack of funds.

Health insurance is beneficial in such situations. These policies cover hospitalization expenses, including pre and post-hospitalization and in-patient treatments. In addition, domiciliary expenses, day care procedures, and much more are covered under health plans. You may choose from different types of plans that suit your personal requirements.

Like most people, you may feel financially secured with a good health insurance policy. Consider a situation where you need to file a claim under this plan. Although the procedure to file a claim is simple and quick, some claims are rejected. Here are three reasons why your claim may be denied.

1. Waiting period

Most health plans include a waiting period. This is the period during which certain pre-specified illnesses are not covered. If you file a claim for one of these illnesses prior to the end of the waiting period, it will be denied. This is one of the commonest reasons why health insurance claim denials occur.

2. Providing inaccurate information

When you provide inaccurate information or fail to disclose all facts related to your health condition, nature of employment, or pre-existing conditions, your claim may be denied. All these are important factors that help insurance companies determine your health insurance eligibility and premium. Withholding crucial information or misrepresenting facts is one of the biggest health insurance claim denial reasons.

If your claim is rejected, there is no reason to be disappointed. In several instances, you will be able to find a solution and overcome claim rejection. It is very important that you understand all the terms and conditions as per the policy document. Furthermore, try to comprehend the reason why your claim was denied. You may call your insurance company to find more details. Here is the procedure on how to appeal a health insurance claim denial.

  • 1. In case your claim was rejected because of incomplete information, you must provide the details to the insurance company. It is crucial to retain a record of all your communication with the insurer in case it is required in the future. If a third party assurance (TPA) was involved, you must inform the TPA.

  • 2. When the insurance company denies a claim because of unfiled documents, you may submit these within the specified period of time. If you used the services of a TPA, you must seek their involvement to help fight the rejection.

  • 3. In the event, the claim was rejected because the insurance company found the treatment unnecessary; you may provide accurate medical details. This may be done by furnishing medical research or an expert opinion. You may need to file an appeal through a health insurance claim denial appeal letter.

Knowing the reason why your claim was denied will help you file an appeal. You must provide all required documents as many times as necessary until a resolution is achieved.

If your issue is still unresolved, you may lodge a written complaint with the Ombudsman. In most instances, this must be done within 30 days after you receive the insurer’s response.

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