Can your health insurance claim really be turned down?

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Health insurance is definitely a basic necessity for every individual. Rising medical and treatment costs are a major source of anxiety for most people in recent times, thereby making health insurance compulsory by all means. Health insurance claims help in covering bills for medical treatment, hospitalization and pre and post hospitalization expenditure. However, you should always be wary of a health insurance claim being denied.

Major factors behind claims being turned down

  • Not disclosing or wrongfully portraying any material facts: Material facts are those facts which can impact the premium rate of the policy. The insurance policy will be issued by the company on the assumption that the customer has truthfully stated all information in the proposal form. The Principle of Utmost Good Faith is the basis behind all contracts of insurance. The insurance company assesses the risk level and premium on the basis of the statement that you have provided. Hiding any key facts or concealing medical conditions will lead to a tricky situation. In case the insurer works out the claimed reason and if it is learned that the customer concealed any important aspect, the claim will be rejected.
  • Improper procedure of claim: There are specific steps to be followed while issuing claims. The insurance company has to be notified about the medical emergency and treatment should be done in a network hospital and the claim form has to be filled up with all bills and reports attached. In case of incorrect filing of claims, they may be turned down.
  • Not adhering to list of exclusions: There is a list of exclusions for every health insurance policy. These will always be kept out of the coverage and these permanent exclusions should be carefully noted before filing a claim.
  • Any temporary exclusions in the policy: In many cases, there is a waiting period for pre-existing diseases and these get coverage only after this period is over. Claims raised for any such temporary exclusions during the waiting period will be rejected.
  • Policy Lapses: If the premium is not paid on time, the insurance policy will cease to exist. There will be no claim paid out by a policy that has lapsed.
Also Read:  5 Things To Do If You are Not Happy With Your Life Insurance Policy

Get Resolutions for Insurance Complaints

What you can do

Make sure that you fully disclose everything, i.e. all material facts while filling up the policy form. Always make sure that you inform the insurer about personal details even if some aspects may increase the premium. Always be aware of claim filing steps and take help from your agent whenever needed. Make sure that you renew your policy annually by paying the premium on time. This will ensure consistent coverage without any lapses.

Shailesh Kumar

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