HOW TO APPEAL AGAINST A HEALTH INSURANCE CLAIM DENIAL

‘’Savings alone are not enough to achieve financial freedom; ensuring your assets with general insurance policies is equally important.’’

Health Insurance Claim Appeal

Getting health insurance is an ideal way to deal with the issues of health, hospitalisation and the emotional trauma that goes with it not only for self-help but also for the benefit of family members. A proper health insurance provides support financially and brings stability to life. However, in some cases insurance companies do reject insurance claims which can lead to mental and financial hardship. So, how can you cope with it?

You have an option to appeal against a rejected claim.

Reasons To Claim Rejection

Insurance companies can reject a plan claim due to several reasons. 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 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 is not covered under the 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.

Appealing Against Rejected Claim

So, as your claim is rejected and you have understood the reason, why, 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 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 Sufficient Documents And Meet The Necessary Requirements

Make sure you understand the terms and conditions of a policy before purchasing it and raising a claim for it. Analyse 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.

Utilise Communication

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.

‘’When you have insurance, you know that you are secured against any unforeseen events in life, and this gives you complete peace of mind.’’

FAQs – Frequently asked questions

Let’s look at some frequent queries on Appeal Against Rejected Health Insurance Claims.

Q1. Are there cases where insurance claims cannot 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.

Q2. Is insurance claim rejected in case of death due to childbirth 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 honour the death claims made and you may also not be able to appeal on the rejection in such a case.

Q3. 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 to be directly or indirectly involved in your death, the insurance provider can withhold the death benefits. Also, if you as the policyholder or the insured die due to any pre-existing health condition or injury that was discovered before buying the policy, the insurance provider may not pay the death benefit to the plan beneficiaries.