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People invest in medical insurance with the expectation that they will receive financial support if any illness strikes. This is crucial as a lack of funds during a medical emergency adds further stress to a situation that is already quite challenging. If a claim gets rejected in such times of need, it dashes all hopes. The fear of claim denial discourages people from getting insured.
The best way to dispel fear is to gather sufficient knowledge about the issue. If you are also looking for more information on claim rejection and how to avoid it, you are at the right place. This article will provide the necessary guidelines related to the above.
Reasons for Claim Rejection
Whether you have obtained health insurance plans for family or individual needs, you must be wary of the following situations that may lead to your claim getting rejected:
Providing Wrong Information
If you provide incorrect and incomplete facts, for instance, about previous policies, family details, demographics, etc. during policy application, your benefits might get cancelled. The insurance company can even terminate the policy if it is proved that false details were given willingly, or with malicious intent.
Hiding Medical History
Pre-existing medical conditions, vulnerability to hereditary diseases, and lifestyle habits like smoking must be disclosed as they influence the premium obligations. Failure to do so can lead to denial of benefits.
Exceeding the Time Limit
Every insurer specifies a time limit within which the claim must be filed. The policy document mentions this condition and it must be adhered to. You must also avoid filing claims during the stipulated waiting period.
Inadequacy of Sum Insured Amount
You cannot file for reimbursement of medical expenses greater than the total policy amount. If you have exhausted the sum insured amount available to you, the insurer will deny your claim request.
Lapse of Policy
If the plan has lapsed due to the expiry of the policy term or due to non-payment of premiums, you will not be able to receive reimbursement for the incurred expenditure.
Tips to Avoid Claim Rejection
By being mindful of the following points, you can maximise the chances of your claim being accepted:
Go Through the Policy Documents Thoroughly
This is the best way to secure yourself from unfortunate surprises. Read the policy’s terms and conditions carefully. Make special note of clauses related to the waiting period, renewability, documentation requirements, exclusion and inclusion list, premium payment frequency, claim-settlement process, and time limit.
Disclose Complete and Accurate Information
It is essential that you give all the relevant information to the insurer such as age, income, previous insurance plans, pre-existing ailments, occupation, etc. While submitting the claim forms, attach them with supporting documents like doctors’ prescriptions, hospital bills, test reports, etc to help the insurer to verify your details.
Select the Right Coverage
Assess the healthcare needs of all your family members before buying health insurance plans for family. Select a plan which offers comprehensive protection for all the diseases you and your family members are most susceptible to. Also, pay attention to the insured amount. Do not commit the mistake of buying a plan with an inadequate amount to save on premium payments. This will defeat the purpose of the insurance.
Pay Premiums on Time
Always make sure that you pay all your premiums timely. Also, comply with co-payment and deductible provisions. Any payment default can be considered by the insurer as a ground for claim rejection. It will also reduce your credit score and make it costly for you to obtain insurance in the future.
To Conclude
While researching which health insurance is best in India and which one to buy, use the above points to increase the probability of claim acceptance. Additionally, check the claim settlement ratio and process of the insurer and customer feedback on it. If despite taking all precautions your genuine claim still gets rejected, you must understand the reason behind it, talk to your insurer, and submit documentary proof. You can also approach an ombudsman or consumer court if the issue does not get resolved.
