7 Reasons Why Your Health Insurance Claim Can Get Rejected

Dec 06, 2022 / Reading Time: Approx. 4 min

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After the Covid-19 pandemic, more and more individuals are becoming aware of the importance of buying a health insurance policy. However, many individuals buy health insurance without thorough research and understanding of the insurance policy's fine print. The lack of seriousness about the consequences can lead to health insurance claim rejection, which becomes quite an exhaustive experience for the policyholder. Hence, to make sure your health insurance claim does not get rejected, it is important to know why your claim can get rejected so that you can take the necessary precautions well in advance. This article elucidates 7 common reasons why your health insurance claim can get rejected.

1. Providing Incorrect Information:

Filling out the health insurance application form is an important task that buyers often neglect. Many times applicants request their insurance agent to fill up the form for themselves to avoid spending time understanding and filling the form. However, the application form should be filled out by the applicant only. An agent may not know all your details and knowingly or unknowingly provide false information. Similarly, many applicants also provide incorrect information while filling out the form. Any genuine mistakes like spelling mistakes in your name, or an attempt to hide crucial information such as age, smoking habit, annual income, etc., can result in your health insurance claim rejection. Furthermore, in case of willingly providing the incorrect details, the insurer has a right to terminate the health insurance policy.

2. Concealing medical history or not disclosing pre-existing diseases:

While buying a health insurance policy, it is necessary to provide accurate details about your medical history. Sometimes people think sharing their medical history will lead to a policy rejection or higher premium, but this is not always the case. If you continue buying a policy by concealing your medical history, the insurer will reject any claims arising out of your existing health condition that was not disclosed while buying the policy. Similarly, it goes with certain lifestyle questions that the insurer asks when you buy or renew a health insurance policy, such as a smoking habit. If a medical complication arises from your undisclosed smoking habit, the insurance company will not cover treatment expenses. If you do not want any claim rejections, do not be secretive about your medical history and lifestyle habits. You might have to pay a slightly higher premium, but you will not have to pay for any medical complications arising out of the disclosed conditions.

7 Reasons Why Your Health Insurance Claim Can Get Rejected
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3. Not renewing the policy on time:

In many cases, the health insurance claim gets rejected because the policy is not renewed. Policyholders sometimes forget to renew their health insurance policy on time or think that they will renew it before it lapses. However, if an insured requires health insurance coverage in this gap, the insurance company will reject the claim. Hence, it is advisable to opt for an auto-debit mandate so that your health insurance policy gets automatically renewed by debiting the premium from your registered bank account.

4. Claiming more than your sum insured:

A policyholder should choose health insurance coverage based on his/her personal requirements and health situation. However, most people decide about health insurance coverage based on the premium they will have to pay. This could lead to inadequate coverage when a medical emergency occurs. If you claim more than your sum insured, the insurance company will approve the claim only for the eligible amount, and you will have to pay for the excess medical expenses from your own pocket. Hence, it is advisable to take into account your family size and health history and analyse the medical expenses you could possibly face in the future. Having adequate health insurance coverage will save you from any out-of-pocket expenses if/when a medical emergency occurs.

5. Claiming during the waiting period:

Generally, most health insurance policies come with a waiting period of 30 days. The waiting period applies to hospitalisation arising due to certain illnesses and diseases. Hospitalisation arising due to an accident is covered in your health insurance right from the policy start. In the case of a critical illness cover, the claim benefit is offered to the insured only if he/she has survived for a minimum of 30 days after the diagnosis of the illness. Similarly, pre-existing diseases or illnesses are existing health conditions that you and/or your family have before purchasing the health insurance policy. Health insurance companies generally do not provide coverage for pre-existing health conditions without a minimum waiting period of 2-4 years. If you claim for these illnesses during the waiting period, your health insurance claim will be rejected. Therefore, before buying the policy and making a claim, it is best to get information about the waiting period.

6. Not reading and understanding the terms and conditions:

Though financial experts constantly advise us to read all policy-related documents carefully before buying a health insurance policy, many people avoid it. The policy document contains all the related information, including product features, terms and conditions, inclusions and exclusions, exemptions, etc., which a policyholder must be aware of. Amongst these, a policyholder must be aware of the policy exclusions. Every health insurance policy has its own list of exclusions that explains the situations that are not covered in the particular policy. The list of exclusions differs from insurer to insurer. Since the insurance companies state in advance that these situations will not be covered under your policy, they do not accept any claims pertaining to those exclusions. Many people ignore reading the list of exclusions and regret it when they have to make a claim and realise the insurer will not accept it. Hence, make sure you read all the policy documents beforehand to make an informed decision and avoid any future disputes. A health insurance policy document may have certain terms that you do not understand; hence, make sure to ask the insurer and understand these terms and conditions before you decide to purchase the policy.


7. Not informing the insurer on time:

Not informing the insurance company within a stipulated period is another reason why your health insurance claim can get rejected. In case of a major accident, it might not be possible for you or your family members to file the insurance claim immediately. Knowing that insurance companies give you sufficient time to raise the claim. However, it is necessary to inform your health insurer within 24 to 48 hours of the hospitalisation, depending on the insurer's terms and conditions. In case you are not in a position to inform the insurer, at least the nominee or any authorised person is expected to do the same.

To conclude:

You can get maximum benefits from a health insurance policy if you do proper research, read and understand the fine print, and choose the add-ons that are best suited to your requirements. Making hasty decisions while buying and filing the claim can lead to the rejection of your health insurance claim.

You can also read 'A Comprehensive Guide to Buy Health Insurance Policy in India', which explains everything you should know when buying a health insurance policy.


Warm Regards,
Ketki Jadhav
Content Writer

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