HOW TO APPEAL AGAINST A HEALTH INSURANCE CLAIM DENIAL

Health insurance plans are designed to provide financial protection during medical emergencies, but what if a health insurance claim is rejected by your health insurance company. This can leave policyholders feeling frustrated and uncertain about their next steps. 

Understanding the common reasons for claim denial, appeal procedure, and list of documents required for the successful claim of health insurance that you rightfully deserve. 

What is Health Insurance Claim?

A health insurance claim is a request made by a policy holder to their insurance provider to  seek financial reimbursement for medical services covered under their health insurance policy. After receiving medical treatment, you or your healthcare provider can file an insurance claim to ensure that the total or partial treatment costs are covered according to the terms of health policy.  

If you are paying regular premiums of your health insurance policy you can claim for expenses, including pre and post hospitalization, surgeries, medications, and routine check-ups, and daycare procedures. A successful claim ensures that the insurer pays out the agreed-upon amount, reducing your out-of-pocket expenses and providing financial relief during times of medical need. 

Reasons for Health Insurance Claim Rejection

Although health insurance offers financial protection during medical emergencies, but claims process can be challenging. Health insurance companies may reject claims for various reasons, leaving policyholders in a difficult situation.As a policyholder you can request to know the reason for the claim and make amends or reapply.

The first step performed by the insurance claims team after receiving a claim application is to look and check for the health policy plan details of the insurer. All the basic details such as names, identification, policy validity, and inclusions are thoroughly checked and verified. Let’s take a look at what the reasons for claim rejection can be;

• The claim raised for the treatment which comes under exclusions of your health policy.
• The claim is raised in case of an expired policy
• The insurer has made a fraudulent claim
• The policyholder did not provide the required supporting documents to support the claim
• The policyholder has not followed the entire process correctly
• The claim is raised for someone who is out of the policy’s purview.

In FY-2023, nearly 4340 death claims were rejected with an equal number of claims under investigation. As per recent survey, up to 30% of insurance buyers submit incorrect information that could lead to rejection of claims.

In case your health insurance claim is rejected, you need not get disheartened. You still have a second chance to get the compensation as you can appeal against the denied or rejected claim.

How to Appeal for Health Insurance Claim Denial

So, as your health policy claim is rejected and you have understood the reason, you can appeal against a rejected insurance claim with the below mentioned important steps.

Check Your Claim Form, Rectify, and Reapply

If your insurance claim gets rejected, you should go through the denial letter and know the reason for rejection. If the insurance provider states a discrepancy in the claim form, you must review the application and rectify the errors to apply again. Ensure that you carefully go through the policy terms and conditions and re-apply within the grace period specified by the insurance company.

Approach an Ombudsman

The Government of India created the Insurance Ombudsman to help policyholders to settle issues or complaints. You can approach the Ombudsman to raise a complaint against your insurance provider mentioning all the details of claim rejection. The complaint can be about delay in claim settlement, premium dispute, misrepresentation of terms and conditions, or other issues with respect to Insurance Act, 1938. Ombudsman is an official who investigates complaints lodged by private citizens against public entities and officials.

The Ombudsman approach is an impartial and an out of court system. The Ombudsman acts as a mediator between the policyholder and the insurer in case of a complaint and arrives at a fair recommendation based on the facts available in the health insurance sector.

Provide Required Documents

Make sure you understand the terms and conditions of a policy before purchasing it and raising a claim for it. Analyze your requirements and know the inclusions and exclusions of health insurance policy clearly. Always submit all the relevant documents to the policy. Suppose the reason for claim denial is insufficient proof to support the claim amount. In that case, you must collect all the bills and other related documents and provide as evidence when you file an appeal against the rejection.

Keep Communication Records

When you appeal against the denied health insurance claim, you must keep a record of the communication through email or messages you may have had with the insurance provider. This may act as proof to support your claim. So, make sure that you always keep the records safe to be used during critical situations like appealing for a rejected claim.

Follow Up

When you appeal against the rejected claim, you must diligently follow up with your insurance provider about the status of the appeal.

Now that you are aware of how to appeal against the rejected claim make sure that you follow the steps carefully and abide by the insurance claim filing rules.

It is easier to opt for an online insurance application as you can easily read and understand the policy inclusions and exclusions as the information is conveyed in a simple and transparent manner in the online method. Chances of misrepresentation are less as you have to provide information yourself.

List of Documents Required to Claim Health Insurance

• Duly Filled Claim Form
• Health Insurance Policy Document
• Identification Proof (Aadhaar Card, Passport, PAN Card, Voter ID, etc.)
• Hospital Discharge Summary
• Doctor’s Prescription and Consultation Papers
• Medical Bills and Receipts
• Diagnostic Reports (X-rays, blood tests, MRI scans, etc.)
• Hospitalization Certificate
• Pre-authorization Form (for Cashless Hospitilization Claims)
• Investigation Reports
• Canceled Cheque or Bank Account Details (for reimbursement)
• Employer's Certificate (if applicable)
• FIR or Police Report (in case of accidents)
• Death Certificate (in case of a claim for a deceased person)
• Any Other Supporting Documents (as requested by the insurer)

Read Also- List of Documents Required at the Time Health Insurance Purchase

FAQs on Health Insurance Claim Denial

 

How Many Times I Can Appeal Against the Denial of Health Insurance Claim?

You can appeal a health insurance claim denial more than once, but the number of appeals allowed and the process can depend on the insurer and policy.

Within How Many Days Do I Need to Appeal Against a Denied Health Insurance Claim?

Timeframe to appeal against a denied health insurance claim may vary depending on the insurer and types of health insurance policy, but typically, you have 30 to 180 days from the date of denial. It is advisable to check your policy documents, terms and conditions for specific deadlines.

 

Will My Health Insurance Premium Increase if My Claim is Denied?

Generally, policy claim denial does not directly impact your health insurance premium. However, multiple claims or certain types of claims could potentially influence future premiums or policy renewals.

 

What Happens if I Submit Incorrect Information on My Health insurance Claim?

You must ensure that the information provided is accurate and truthful as submitting incorrect information can lead to claim denial, penalties or legal action in some cases. 

 

Are There Cases Wheere Insurance Claims Can Not be Appealed for?

Yes. If the cause of death is due to the influence of alcohol or drugs, suicide, or adventurous sports-related activity that includes racing, paragliding, skydiving, bungee jumping, and water rafting, the rejected insurance claim cannot be appealed for, in such cases.

Is Health Claim Rejected in Case of Death Due to Childborth for Women Policyholders?

Yes, that may be. For female policyholders, if you are unable to disclose your pregnancy and die during childbirth due to medical complications, the insurance company might not honor the death claims made and you may also not be able to appeal on the rejection in such a case.

Is the Claim rejected in Case of Any Other Specific Cases?

Yes. In homicidal cases, if the listed beneficiary is found guilty by the court, the insurance provider can withhold the death benefits. Also, if you as the policyholder or the insured die due to any pre-existing health conditions or injury that was discovered before buying the policy, the insurance provider may not pay the death benefit to beneficiaries.