10 Sneaky Reasons Your Health Insurance Claim May Not Get Approved

In situations of unforeseen health-related crises, a health insurance policy comes in to save the day, promising financial help and facilitating the burden of healthcare costs. Notwithstanding, the claim settlement process isn’t direct all the time. Now and then, minor oversights or false impressions can prompt claim dismissal, leaving you feeling disheartened and financially unstable. In this blog, we will uncover 10 reasons why your medical coverage guarantee may get denied.

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1. Understanding Policy Exclusions

Each health insurance policy has exclusions and conditions under which claims are not covered. These can go from prior conditions not disclosed during the beginning of the policy to specific treatments expressly excluded in the policy. Cautiously review your policy, comprehend the exclusions completely, and explain any questions to your insurer to avoid surprises during the claims procedure.

2. Incomplete Documentation

Organised documentation is key to having a seamless claims procedure. Ensure that you present all vital documents required under your policy. This normally incorporates clinical records, doctor prescriptions, diagnosis reports, and bills. Deficient or missing records can essentially defer or try and lead to claim dismissal, causing pointless pressure and financial strain.

3. Pre-authorisation Problems

Certain procedures require pre-approval from your insurer before availing them. The inability to acquire pre-approval, particularly for costly or specialised procedures, can lead to claim dismissal. Get to know your strategy’s pre-approval necessities and stick to them constantly to guarantee your claim sails through without a hitch.

4. Not Renewing the Policy on Time

The lapse of policy is one of the main reasons for the dismissal of a health insurance claim. Health insurance policies are generally valid for one year and should be restored yearly. If you neglected to renew the insurance on time and, in the meantime, fell sick during that period, your policy would be pointless, and your claims would be dismissed.

5. Not Adhering to Claim Filing Timelines

There isn’t a moment to spare while recording claims. Every health insurance plan specifies a particular period for submission of the claim, commonly ranging from 30 to 180 days from the date of discharge. Surpassing this period can prompt claim dismissal. Present your claim documents expeditiously to keep away from unnecessary delays and complexities.

6. Failing to Disclose Pre-existing Conditions

While acquiring a health insurance plan, complete transparency concerning prior conditions is important. Even unrelated illnesses can be grounds for rejecting claims if not disclosed earlier or if their severity is misrepresented. Tell the truth and be upfront about your clinical history to ensure your policy stays valid and claims are handled reasonably.

7. Exceeding Coverage Boundaries

A sum assured is the maximum amount a health insurance policy will pay for medical expenses. Ensure your treatment costs stay within the limit as far as possible. Surpassing the assured sum can bring about a partial claim settlement or even dismissal of the claim, leaving you responsible for the leftover expenses. So, be mindful of your coverage limits during your treatment and hospital stay.

8. Overlooking Waiting Periods

Numerous health insurance policies have waiting periods for specific treatment procedures or prior conditions. This implies you probably won’t be qualified for the inclusion of a particular condition until a period has passed after the start of the policy. Understanding and sticking to these waiting periods is critical to keep claim dismissal and ineligibility at bay.

9. Updated Policy Terms and Conditions

At times, insurers may adjust the insurance terms and conditions, for example, the coverage benefits and premiums. As a result, your claim may get denied if both your coverage and your policy have been altered.

10. Fraudulent Claims

Deliberately submitting bogus or fabricated data in your claim is fraud and can have serious outcomes. This includes fabricating medical records, exaggerating symptoms, and requesting reimbursement for non-covered expenses. Taking part in such unscrupulous practices puts your claim in danger and risks cancellation of the policy and possible legal repercussions.

Conclusion

Understanding these reasons for claim rejection enables you to approach the process with informed vigilance, despite the complexity of the health insurance landscape. By cautiously evaluating your insurance terms, carefully setting up your claim documents, and sticking to pre-authorisation necessities, timelines, and inclusion limits, you can fundamentally expand your possibilities of claim approval and ensure seamless procedures during health-related crises. Keep in mind that being honest and open with your insurer and seeking professional guidance when required are tools for securing your well-being.

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*Terms and conditions apply. The information provided in this article is generic in nature and for informational purposes only. It is not a substitute for specific advice in your own circumstances. You are recommended to obtain specific professional advice from before you take any/refrain from any action. Tax benefits are subject to changes in tax laws. Please contact your tax consultant for an exact calculation of your tax liabilities.| EL/BLOGS/24-25/05