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What are the most common reasons for Health Claims Rejection: The Series: Part 7

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Admission for Diagnostic Purposes

Healthcare starts with and depends on diagnostics, whether it is diabetes, cancer, or any other health threats. Diagnostics are at the front and center. The purpose of diagnostics is to gather precise information to aid in early detection, prevention and monitoring of diseases. Moreover, diagnostics are vital in the creation and implementation of treatment plans. Thus, the importance of diagnostics cannot be undermined. However, what happens is that sometimes people visit clinics or hospitals for a diagnosis, but due to the severity of the problem, they are advised to get hospitalized. 

The suffering person with pain has no option but to follow the doctor’s advice. However, when it comes to claiming health insurance for the medical expense incurred during hospitalization, the insurance companies reject the claim stating that the hospitalization was not warranted/ required. 

Today, we will talk about another major reason for rejecting health claims “patient admitted for diagnostic purposes but hospitalization was not required.” 

Insurance Samadhan

Case Study

Insurance Samadhan is a platform where people register their insurance-related issues for expert assistance. Recently, we received a call from Mr. Rahul Pal, who was hospitalized at Neema Hospital for the treatment of Enteric Fever with chills, cold, vomiting, and related issues for which the doctor advised him to get hospitalized. Mr. Rahul had no other option but to listen to the doctor and got hospitalized. 

After being admitted to the hospital for two days, Mr. Rahul was discharged from the hospital with a huge medical bill, which he was not worried about since he had health insurance. To his surprise, the health insurance company rejected the claim stating that hospitalization was not required for the mentioned symptoms. He was shocked to see the company’s behavior as he never thought he had done something wrong. So, he decided to challenge the insurer. 

He contacted Insurance Samadhan, and we analyzed the case thoroughly. We saw that Mr. Rahul had all the relevant documents with the doctor’s signature that stated admission was necessary as oral treatment was not improving the patient’s health. 

When the Ombudsman heard the case with all the facts, it was decided that the insurer had wrongfully rejected the health claim. Thus, Mr. Rahul’s case was settled, and he got back his hard-earned money but not the complete amount. And there is a reason: only a few expenses are covered under pre and post-hospitalization. We will talk about Pre and Post hospitalization expenses in detail later in the article.

health claim rejected

Don’t Be Ignorant – Know Your Rights

Don’t be ignorant about your rights as a policyholder. Understanding your rights is crucial when dealing with health insurance claims. Insurance companies may sometimes wrongfully reject claims, leaving policyholders confused. Knowing your rights empowers you to challenge claim denials with confidence. This series aims to educate you on policy terms, claim procedures to avoid misunderstandings with insurers. 

In Mr. Rahul Pal’s case, he faced claim rejection after being hospitalized for diagnostic purposes. Unaware of his rights, he was shocked by the insurer’s behavior and questioned if he had done something wrong. Seeking help from Insurance Samadhan, he learned about his rights as a policyholder.

The above case is related to pre and post-hospitalization expenses, which are the medical costs incurred by a patient before and after their hospitalization for a specific medical condition or treatment. So, let us take a look at the subject and how you can easily make a claim. 

Insurance Samadhan

How to Claim Pre and Post-Hospitalization Expenses?

Step 1: Ensure the health claim is for treatment of the same condition the patient was admitted for.

Step 2: Complete the required claim form and attach hospital bills and relevant documents 

(diagnosis confirmation, prescriptions, discharge summary, etc). Submit to your insurer and TPA.

Step 3: Submit the claim within the specified time period (usually 30-60 days after hospitalization, check with your insurer).

Step 4: The insurer will verify the documents. The claim will be accepted if expenses are related to the admitted condition. 

Usually, we miss a few things that might lead to claim rejection, but if you follow the above points, it will likely happen. 

Documents Required 

Claim Form: Complete and sign the claim form your health insurance company provided. Make sure all details are accurate.

Hospital Bills: Attach the original bills or receipts from the hospital for the pre and post-hospitalization expenses. The bills should clearly mention the treatments, consultations, medications, and other services availed.

Diagnosis Confirmation: Include documents confirming the medical condition diagnosis for which the patient was admitted to the hospital. 

Discharge Summary: Obtain the discharge summary from the hospital detailing the treatment received during the hospitalization.

Prescriptions: Provide copies of prescriptions issued by the treating doctor, which show the medications prescribed during the pre and post-hospitalization period.

Follow-up Reports: If there were any follow-up consultations or medical check-ups after hospital discharge, include the relevant reports and bills.

Relevant Medical Reports: Submit any other relevant medical reports or documents related to the pre and post-hospitalization treatments.

Providing the insurance company with all necessary documents will facilitate a streamlined and expedited claim processing experience.

Bottom Line 

In today’s blog, we have covered the common reasons for the rejection of health claims, focusing on “patient admitted for diagnostic purposes, but hospitalization was not required.” Understanding your rights as a policyholder and being aware of the claim process is crucial to avoid misunderstandings with insurers. The case study of Mr. Rahul Pal serves as a reminder that if stuck, you can always ask for help from Insurance Samadhan, as we will be really happy to help people whose claims have been wrongfully rejected. Additionally, we provided a step-by-step guide on claiming pre and post-hospitalization expenses, emphasizing the importance of submitting the required documents within the specified time frame. Stay informed and confidently navigate the health insurance journey.

That is all from our side today. Hope this article helped you gain enough clarity. Stay tuned for next week, where we will be covering “Discrepancy in Documents/ Fraud.” It is another very important reason for claim rejection.

Click here to register your complaint with Insurance Samadhan

Also Read:  How to Choose the Right Health Insurance Policy for Your Needs

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Visit our website: insurancesamadhan.com

Call us on +91 9513631312

WhatsApp:  9910998252

Mail us at corporate@insurancesamadhan.com

Shikhar Vashisht

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