July 29, 2022 Last updated August 13th, 2022 751 Reads share

How to Appeal Against a Denied Health Insurance Claim in India

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Why are Health Insurance Claims Rejected?

Buying a health insurance plan is the best way to keep yourself and your loved ones protected against unexpected medical expenses, however, there may also be a rare situation where your insurance provider might reject your insurance claim. An insurance company can reject a claim only on strong grounds. Fortunately, you will have the option to reapply again if your insurance claim is initially rejected due to an error. Here are some of the reasons why your health claim might get rejected by the insurance provider: 

  • If you wish to claim heath insurance for medical expenses which is not covered under your health insurance plan inclusions, your claim will get rejected. 
  • If you raise a health insurance claim for medical expenses or treatment on a policy that has expired, your insurance claim will be rejected. 
  • If you have provided any incorrect information in your insurance claim form, your insurance provider will likely reject your health claim. 
  • If a health insurance claim is raised for someone who is not insured under the policy, the insurance claim will be rejected. 
  • If you have submitted incorrect documentation such as incomplete hospital bills and records that do not match your insurance claim amount, your health insurance claim may get rejected. 

The first step to ensuring that your claim does not get rejected is to read the insurance policy document in detail to understand all the terms and conditions. Many times insurance holders don’t read the documents properly which leads to many problems later regarding their claims. Reading them will help you avoid any unintentional mistakes while making an insurance claim. Next, double-check that all the information you have filled in the insurance claim form is accurate and all the attached documents are in order. Even minor mistakes in your claim form and documents can lead to your insurance claim getting rejected. If your insurance claim still gets rejected, there are certain actions you can take. 

Steps to Take if Your Insurance Claim Gets Rejected 

When the insurance company rejects your claim, they will provide the reason behind the rejection. In case your claim has been denied due to errors in the form or the documents, you can reapply for the insurance claim with the correctly filled form and documentation the second time around. It is vital to understand the reason for the initial rejection of your insurance claim, otherwise, chances are high that your claim will be rejected again. At the time of reapplying your claim, make sure you save email copies of the correspondence with your insurer for proof. 

It is important to note, however, that if your insurance claim has been rejected due to the expiration of the policy, then your claim will not be accepted under any circumstances. If you reapply for your insurance claim, and your insurer still rejects your insurance claim for no valid reason, you can choose to approach the Insurance Ombudsman. 

Approaching the Insurance Ombudsman 

The insurance Ombudsman is the final option or the last resort that policyholders can turn to if their insurance claim has been denied again and again. The government of India has created the Insurance Ombudsman to protect the interest of the policyholders and to allow them to settle their claims in a fair and transparent manner. You can send a written complaint to the Insurance Ombudsman with the details of your rejected insurance claim and information about your insurance provider. The Insurance Ombudsman will look into your case and serve as the mediator between you (the policyholder) and your insurance provider. The Ombudsman will also give an impartial recommendation to the insurance company to clear the claim if they are at fault. However, if the Ombudsman rules that the insurance company is right and has rejected the claim for a valid reason, then your claim will remain denied. 


To Conclude 

Above everything, it is also important to ensure that you do not make any mistakes while applying for a claim the first time around. At the time of buying the health insurance plan, you have to check that all the medical conditions and illnesses you need coverage for are included in the policy, along with any other kinds of inclusions that you feel you may need in the future. More importantly, look for an insurance plan that offers the cashless network hospitals facility. With cashless health insurance, you can directly visit a network hospital in case of a medical emergency. Be well aware of the healthcare system of that hospital. The network hospital will verify your insurance details swiftly and the treatment of the insured will begin. You will not have to pay any bills since the insurer will directly pay for the hospital bills, thereby reducing the chances of your claim being rejected to almost zero. 

Bhavika Shukla

Bhavika Shukla

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