Question 1

Reasons for Claim Rejection

Accepted Answer

1. Inaccurate Information: one of the primary reasons for claim delays needs to be completed or accurate information provided during the claims submission. More details, documents, or errors in the claim form must be required to lead to back-and-forth communication between the policyholder and the insurance company, prolonging the settlement process.

2. Lack of Documentation: Supporting documentation is essential for claim processing. Whether it's medical records, photographs, or other relevant evidence, insufficient or missing documentation can lead to delays.

3. Error in Claim Form: Filling out the claim form incorrectly or providing inaccurate information can cause delays in claim processing. Mistakes such as misspelled names, incorrect policy numbers, or missing details can lead to confusion and require additional time for verification and correction. Therefore, it is crucial to carefully review the claim form before submission to ensure all information is accurate and complete.

4. Out-of-Network Hospital: Insurance company networks can change yearly, and patients may need to realize this. In this case, the patient’s cashless claim request will be denied.

Question 2

How to Appeal Against a Rejected Claim

Accepted Answer

Now that we have understood some ways that can lead to claim rejection let us look at the steps to take if your insurance claim is rejected.

1. Contact the Insurance Company: The first step is to contact the insurance company via phone, email, or by visiting the branch. Then, you can request the senior management to look into your situation to determine if anything can be done.

2. Call for grievance redressal via IRDAI: The Policyholder's Protection & Grievance Redressal Department of the Insurance Regulatory and Development Authority of India includes a Grievance Redressal Cell dedicated to addressing complaints and grievances raised by policyholders. This specialized cell liaises with the relevant insurance companies to resolve the issues and provide redressal.

3. Contact Insurance Ombudsman: The Office of the Insurance Ombudsman, established under the Insurance Ombudsman Rules, 2017, serves as an alternative platform for grievance redressal. Its primary objective is to provide a quick, cost-effective resolution for policyholders who complain against insurance companies, intermediaries, or insurance brokers.

Insurance Claim Denial

Appeal against Insurance Claim Denial