Five reasons that claims
rejection in 2024. And how to
avoid rejection
One of the biggest concerns customers have while purchasing health insurance policies is whether the company will pay their claims on time, and if they do will it be in full or not. This is also one of the key factors that impacts the customer purchase process and satisfaction. While there are many reasons that a health insurance claim can be rejected even by the best insurance companies, here are the top 5 reasons for claims rejection and what you can do to avoid it.
Claims Rejection - Incorrect form filling & medical non-disclosure: This is a very common occurrence as most of the forms are filled by the agents. In their rush to get the job done they often miss out on vital details or put incorrect information. Some dishonest salesmen even misstate facts hoping that their deed will not be discovered. And by the time it does they might have left the company. Hence, it is very important that you be careful about the information that you are putting in the proposal form. In case you have already purchased the policy we still encourage you to review your policy document.
One thing you must know is that per law there is a moratorium of 5 years after which health insurer cannot reject a claim for misrepresentation or non-disclosure of material facts unless insurer can prove intent to defraud.
- Filing a claim during waiting period: All health insurance policies have a waiting period for various conditions. It’s a common misconception that waiting period is only for pre-existing diseases It can also be for occasions like pregnancy (if the policy has maternity cover). When you are buying a policy make sure you understand this important aspect. It is important to note that if your policy lapses, for whatever reasons, these waiting periods will typically begin anew.
The maximum waiting period in health insurance has now been made 36 months.
- Filing claims for exclusion: In an ideal world all medical expenses would be covered by your insurance. However, that type of insurance would be too expensive for most customers. Hence, all health policies have conditions and procedures that they wont cover. This is very important information which does not get enough attention at the time of policy purchase. The issue arises when a claim is made and it gets rejected
- Inaccurate understanding of Sum Assured Sublimit & Refill: Many customers do not realise the sum assured of health insurance policy is different from life insurance. In life insurance sum assured is absolute and guaranteed and will be paid out in the exact amount. Health insurance contracts are different in two important ways.
Firstly, they are contracts of indemnity which means that the payout is equal to expenses and not sum assured. So, you can have a health insurance policy of 50 lacs and yet if expenses are 1.5 lacs that is all that will be paid. Secondly, not all expenses are covered. So, while the taxi you had to take to get to the hospital is an expense due to illness, most health insurance policies don’t cover it. Also, even among the expenses that are covered there is a sublimit. Taking the previous example, a policy with sum assured of 50 lacs does not mean that a hospital room rent of Rs 1 lac per day will automatically be covered. There are limits to each expense, called the sublimit.
Refill of sum assured is another point of contention. Refill feature in health insurance was introduced by insures as an innovation which customers would appreciate and benefit from. It means that in case sum assured of a policy gets exhausted in a year, the customer can still be covered but under some restrictions e.g. the expense has to be for a different disease. It is important to understand how this feature works in your policy.
It’s crucial to understand the concept of sublimit.
- Incomplete documentation and delayed filing: This is another big cause for claims dispute. While this problem has reduced with rapid expansion of cashless claims but 40% of the claims in India are still paid after submission of bills. Even in cashless claims there is a requirement for customer to submit the documents. And in a hospitalisation situation where the customer is under lot of emotional stress, this simple step goes wrong leading to complications in the process. A simple way to avoid this is to have a checklist of documents you will need in case of hospitalisation and having a dedicated physical folder in which to organise the same. This will save you a lot of hassle. Also, we recommend that you digitise your documents as and when you are getting them in case the folder gets misplaced. These simple steps will go a long way in ensuring a smooth claims process.
But what if the health insurance company is wrong?
While taking care of above 5 factors will make sure that your chances of claims being rejected become minimal there is always a chance that your claim is rejected wrongly. In such a case you need not despair. You can take up your complaint at various levels and get your claims rejection overturned. We at Carepal Secure will be happy to help you with your claims related issues. Drop us a line at [email protected] or message us at +91-8591959466. We will be happy to help.
Conclusion
Secure is designed to provide you and your family with comprehensive, accessible, and affordable healthcare solutions. Whether you’re an individual, a family, or a senior citizen, there’s a plan designed to provide financial security and peace of mind.
Some key reasons why you should choose CarePal Secure are:
Extensive Coverage: Get access to a wide network of hospitals for cashless treatments, covering everything from regular health check-ups to major hospitalisations.
No Waiting Period for Essential Coverage: CarePal Secure offers immediate access to essential healthcare benefits so that yCarePal ou can receive critical medical treatment without long approval delays.
24/7 Medical Assistance & Claims Support: Our dedicated helpdesk is available round-the-clock to assist you with medical emergencies, claim processing, and consultation bookings.
Teleconsultations & Healthcare Discounts: Our seamless teleconsultation services allow you to access specialists across 18+ medical fields. Additionally, you can enjoy significant savings on medicines, diagnostic tests, and outpatient care, making quality healthcare more affordable.
Affordable Plans with Super Top-Up Options: Choose from a range of budget-friendly plans for individuals, families, and seniors. Our super top-up policy for seniors provides additional financial protection, covering larger medical expenses at a lower cost.
Tax Benefits Under Section 80D: The premiums paid toward CarePal Secure health insurance are tax-deductible, helping you save money while ensuring comprehensive coverage for yourself and your family.
With trusted partners nationwide, CarePal Secure ensures that quality healthcare is always within reach. So what are you waiting for? Join 80,000+ satisfied customers who trust CarePal Secure for their healthcare needs.
Get in touch with us to know the right plan for you.
