Key Tips on Avoiding Rejection of Insurance Claims

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Emergencies do not see any time or day but when it comes to claiming your medical benefits from your insurance agent, it is no less than the onset of another medical incidence. Take the case of Delhi based Mohan Poddar, a 59 year old businessman, who was diagnosed with vertigo which causes dizziness and the sensation of the room spinning even with a slight change in head position. Mr. Poddar has diligently been paying a sum of Rs. 23,000 every year since 2008 and when in 2011 he was hospitalized, he had to pay the bill from his own pocket as the health insurer’s Third Party Administrator (TPA) refused his claim of cashless facility citing that the vertigo have arisen from Mr. Poddar’s pre-existing heart ailment and they need more time to scrutinize the claim. This has shaken this businessman’s sense of security as he felt cheated because medically, vertigo does not arise from a heart ailment.

Even though these rejections do not mean the person cannot take the reimbursement route nor does it mean that such incidence will occur in the future, but it does induce a feeling of distrust towards the insurance company and the idea of medical insurance on the whole. It is part of the insurance company’s job profile to pay genuine claims only since attaining to bogus claims will only be a problem for the customers as they will have to deal with higher premium in the future. It is therefore also the responsibility of the policyholder to follow all the policies and guidelines when applying for the insurance and while filing for a claim to ensure hassle-free approval.

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Get Resolutions for Insurance Complaints

Here are a few tips to ensure your claim filing does not get rejected:

  • Always read the fine prints of the policy, the terms and conditions and the procedure and waiting period of the claim to be approved. Ask questions and do not settle for anything less than an honest answer because often it is seen that the customer is not aware of the exclusions which come with an asterisk mark upon it like, they apply for a policy which claims to cover any pre-existing illnesses but the asterisk mark mentions that the waiting time is 4 years. So if you are hospitalized before that time period, your insurance agency will not honor your claim due to technicality. Insurance companies also offer a free look period of 15 days where the policyholder can change the contract or cancel it altogether.
  • Non-disclosure, partial disclosure and wrong disclosure are some of the most common factors which cause a claim to be rejected. Significant facts like age, income, nature of the occupation, medical conditions and history are often overlooked by the policy agent which becomes a hindrance for the customer. As a policyholder, you must understand that all policies fall under guidelines and underwritten principles and you must acknowledge them and know them completely before investing. It is also the duty of the insurance company to be upright with their prospective clients in terms of the information required and the role it plays while making a claim.
  • Most often a customer leaves the proposal form filling up to intermediaries or third-party agencies which gives rise to gaps leading to serious declaration mistakes. The customer should fill the form themselves and provide all relevant and genuine documents at the time of buying the policy. This is one of the most important steps because the third party may not be fully aware of your medical history and most of them fill in wrong information just to hasten the application approval procedure to earn their commission. Incorrect or missing details cause a claim to be rejected. Even after you have filled your form and have been provided with a photocopy of the same, go through it carefully and check if there have been any alterations in which case, contact the provider of the insurance.
  • Medical insurance falls under the general insurance segment and this along with motor insurance faces most of the claim rejection. Many private hospitals and garages often add unnecessary repairs and medical procedures in the bill which, according to the insurer’s guideline, are not covered by the policy. Inflation being on the rise, these added charges cost the person to face claim rejection and then the whole amount goes out of their pocket. As you read the policy guidelines, you need to make sure that you are not being led to a false sense of security and also be aware of what treatments and repairs are required and make a bill accordingly.
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At the end of the day, insurance policies are a business and like every other business, they focus on making profits. As a customer, it is your duty to make sure you are not cheated and it is also your responsibility to make sure that the insurance companies provide you with total transparent details.

Shailesh Kumar

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