Health Claim Rejected? What can You Do?

You bought health insurance so that in time of need, you will have the much needed financial support to bear the huge medical expenses. 

Going through medical issues is already a stressful situation to be in. On top of that - if your health claim gets rejected, it becomes both a financial and mental burden. 

Any issue in the claim process may unfortunately lead to your health claim getting rejected. 

But wait, did you know that you have the option to appeal against the claim rejection decision?
Yes, you read that right! You can reapply and ask the insurance company to reconsider your claim approval even after rejection! 

How can you appeal against claim rejection?

Whenever an insurance company rejects a claim, they give a rejection reason. So, before going for an appeal, you should check and understand why your claim is rejected. 

Some common reasons for claim rejection are: 

• Your balance sum insured got exhausted
• Your documents were not complete
• There was undue delay in filing the claim
• The disease or treatment for which claim is filed is not covered in your policy
• Your policy got expired
• The documents submitted are not authentic or there’s misrepresentation of facts
• The disease or treatment for which claim is filed has a waiting period

So, the first thing you do is to clearly understand your rejection reason. When you know the reason, you can try to rectify it and reapply for the claim. 
For example, there might be a missing document or error in the basic details of the patient whose documents have been filed. In this case, you can reapply and submit the remaining documents and request for claim approval. 

Your claim will most likely be not eligible if the claim rejection reason is waiting period, policy expiry or treatment not covered under the policy coverage. 

What next?

Reach out to your TPA or insurance company and write an email to appeal for reconsideration. Written communication is advisable as proof of communication.

Go through your documents well.

• If your rejection reason was missing or incomplete documents, submit the remaining required documents.
• If there was some error in forms or documents, make sure to rectify and reapply with the correct documents.
• If the insurer was not satisfied that hospitalization was required, you can connect the hospital and talk to your doctor to give a written application specifying why hospital stay was necessary for treatment. 

Now that you have all corrected and sufficient documents, you can write a formal letter or email to your insurer and TPA attesting all documents and clearly mentioning how your claim is genuine and should be approved. 

You approached and tried but what if you don’t get any response or even if you do, you’re unhappy with it? You still have another way out. 

You can approach an Ombudsman within 30 days of receiving or not receiving a response from your insurer. The Ombudsman is responsible to look into your complaint and recommend a solution for your appeal by acting as a mediator between you and the insurer. 

Conclusion

Claim rejection is indeed disappointing and stressful. It’s great to have an option to appeal against this decision. However, it's a time consuming and long process. Thus, you should always try from your end to avoid getting your claim rejected by making sure that:

• You renew your policy timely so it’s always available for claiming at the time of a medical emergency
• You submit all required documents as desired by your insurance company and TPA
• There are no errors in the claim form 
• All KYC details match in the policy and other filing documents
• Raise the claim request within the time limit.