How to make sure that your health insurance claims are not denied

This month I went through minor surgery & was hospitalized for couple of days; there I though about writing this post – what else you can think in hospital other than bills or insurance claim settlement 🙂

You did the right thing by buying health insurance for you and your loved ones. But you have to take care of a few more things so that the health insurance claim is not denied when it is required. Unfortunately, the claimant is at fault in many cases.

health insurance claims

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Let us look at some pointers to keep in mind so that a claim for health insurance is not denied –

Health Insurance Claim

Understand your Health Insurance Policy –

Before you buy the insurance cover, you should read the policy document and all terms and conditions carefully. You should clear all your doubts with the company representative and ask him to explain whatever you did not understand. The agent/company is keen to sell the policy and may not lay down all the facts and figures. You should make sure that you know everything about the policy. It is important to know what the policy covers and what it excludes. Some policies do have a cap on room rent (very tricks, make sure you stay in room approved by your insurer), some policies cover treatment at home and other policies may not cover certain procedures. There are policies that cover the family. You should be aware who is covered and who is not.

ReadTerms commonly used in health insurance policy

Take care of timeline and dates –

You have to remember to renew the policy before the due date else your policy will be treated as a new one and the benefits of continuous policy cover  like no-claim bonus would lapse. Moreover the premiums paid earlier will be of no use. It is important to check if the cover is for hospitalization for 24 hours (I came across a case where hospital discharged patient in 23 hrs – claim was denied) or more or even less than that duration. You should also make the claim within the timeline indicated by the insurer else it can get rejected.

Submit all the required information –

While buying the insurance policy, you should disclose all required details. Many times claims are rejected because at the time of buying the policy, all facts were not disclosed or wrong information or partial information was given to the insurer. Information can be related to spelling of name, age, type of occupation, existing medical conditions etc.  You should give details of income and other policies. If you conceal relevant information, the claim can be rejected. The premium also depends on the relevant information you give to the insurer.

It is also important to fill in all the information in the insurance application form yourself and not allow the agent to complete the form or thoroughly check that. This will help in the form being more accurate and you are aware of the information given to the company.

Read everyting about – Health insurance policy portability

Cashless facility versus Reimbursement –

The insurance policy will have a list of clinics and hospitals that it has a tie-up with. These are network hospitals. If you seek treatment in one of these networked hospitals, you should follow the process to request for cashless treatment and the bills to the extent of the cover will be settled by the insurer/Third Party Administrator if all process and documentation is in place. If you are not in a network hospital, you should inform the insurer’s or TPA about the hospitalization and follow the claim process. You will have to pay the expenses yourself and then submit the hospital bills with relevant documentation such as prescriptions, reports, diagnoses etc. for reimbursement. (2 years back when I went through appendix operation, I was denied one medical bill because I lost prescription slip – that was for pre hospitalization expense)

Know what can be claimed –

The insurance cover will be for a certain amount and for certain conditions. You need to know what can be claimed and what cannot be claimed. You can claim again but it is better to claim properly the first time. You should not claim for ailments and treatments that are not covered by the policy.

Read – Should you buy medical insurance if you are covered by employer

Handle Rejection –

If your claim is rejected and you do not find the grounds of rejection satisfactory, then you can reach out to the grievance cell of the insurer. If that is also not satisfactory, you should reach out to the IRDA ombudsman within a year of the claim being rejected. You should submit a written complaint and you will be asked to go for a hearing and the ombudsman will give a decision. You can approach the consumer courts if you are still dissatisfied with the verdict.(One of my friends faced this situation where his claim was denied but when he approached consumer court, he got full amount)

Few Random Points

  • Cashless facility should be preferred over reimbursement
  • This point may not be relevant today but I can visualize that it will be very relevant in coming years. You should not go to BEST hospital for not very critical issues or BEST possible rooms in any hospital. You may have insurance policy which gives you complete flexibility & luxury but in future they will use this data to increase your premiums. (data mining is becoming talk of the town & you will be surprised data scientist is ranked as best job – Media is ranked as worst job)
  • Use your employers insurance policy
  • If you have insurance from your employer – still you should have a separate mediclaim or at least a top up cover.
  • Prescription, reports & bills should be kept for pre & post hospitalization expenses

It is important to understand your health insurance policy and the claim process properly so that when you or a loved one is unwell, you can worry less about the financial aspect of the medical treatment and concentrate your energies on the medical treatment. Must share your experience with health insurance claim settlement.

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{ 3 comments… add one }
  • Satish April 22, 2016, 3:55 PM

    Hi Nice article on medclaim

    Am 40 I have health cover from my employer for 2.5 lacs, am planning to have one by my own for SA 5 Lacks, have zeored in on Religare Care floater policy after researching for a month and so through blogs and website, the features and benefits seems to be better compared with other insurers. I don’t have any other medical problems except diabetic type2 not that too much and i checked with the CSR of insurer company they told they will give the policy for diabetic with extra premium loading. Some of the customer review forums like mouthshut.com have given negative feedback on the policy saying that most of the claims get rejected by the insurer simply stating its a pre-existing alliments not covered like that.

    Question1. As per my opinion the policy features are very good, please give you opinion on the same without fail.

    Question2. I came to know that if I control my sugar levels before giving up the medical check up with the insurer premium loading will be less based on the sugarlevel pls clarify?

  • Anirudh Singh April 24, 2016, 8:52 PM

    Thanks for this post! I recently bought a health insurance policy. I will have to take care of all these points now.

  • HARESH May 2, 2016, 9:07 AM

    Dear Sir,

    In this matter i want to add more i.e. denied by health insurance company. in last year i admit in hospital for chest pain. and i admit in network hospital. after two day and checkout from hospital i have to pay approx 20% of bill amt. in cash. because of hospital charge some addition exp. i.e. service charge and which type of service charges, hospital not clear properly. they charge 15% service charges on bill amt. like they give food and bedsheet changes and cleaning charges, nurce charge. and some charges extra also. and for same treatment i have prehospital exp. bills of same hospital i.e network hospital. and due to some technical problem X-Ray given but report of X-ray they given to directly doctor mail. so due to not produce of X-ray report they reject a claim without any prior intimation. and and doctor suggest some addtional test before admit in hospital. in that also some test they dined due to they are not cover. when we assist to hospital why they shown other charges room cleaning charges or misc exp. when they collect room rent they can include in room chares. they told this is our policy, we can not include this amt. and for that insurance denied the claim of additional exp. and also insurance company not ask with patient if any doubt they have. and also they are not ask with network hospital regarding pre-hospital bill. they are only insist to patient to produce the bill any how after when we asking why they denied this bill.
    IRDA get the action on this type of health insurance, ie. when patient go to network hospital than each and every medical exp. should be cover. patient not goes for picnic. if doctor write some test than it should be cover and if any test report is misplaced but bill is available they can ask to hospital and get the report.

    and i request to Government authority of hospital also take the action, why they charges misc. exp. or service charges. why they are not include in room rent. i pay 2500/- per day room rent which is approx “THREE STAR HOTEL” room rent. after that theycharges this charges and that charges. which is cheated to patient.

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