6 Ways to avoid Health Insurance Claim rejection

Ways to avoid Health Insurance Claim rejectionWays to avoid Health Insurance Claim rejection

In today’s fast track world, if you have a health insurance plan, you can get easy access to the best medical care and treatment and also financially protected. Whenever there is a medical emergency, a health insurance policy guarantees peace of mind and ensures that you and your family will receive the best treatment at the hospital of your choice. However, there are several reasons why health insurance claims are denied. What is Health Insurance Plan? What are the possible ways insurance company can reject your health insurance claim? What are the various ways to avoid health insurance claim rejection or denial? How should we handle if an insurance claim is denied?

Also Read: Top Health Insurance plans for your parents or Senior Citizens

What is Health Insurance Plan?

Health insurance is an insurance that covers your medical and surgical expenses. It reimburses the expense incurred due to injury or illness and pays, the care provider of the insured individual directly. According to the terms of insurance coverage, either insurance company directly reimburses the hospital or the insured pays the cost by himself and subsequently reimbursed by insurance companies. While the increase in food and clothing prices are in single digit medical care costs usually increased in double digits.

Do we need a health insurance plan?

According to the recent study, a heart surgery performed today @ Rs 2 lakhs will cost over Rs 3.22 lakhs after five years and after 10 years, it will be Rs 5.19 and Rs 8.35 lakhs after 15 years.

For an individual who has not saved that much amount of money, paying for funds in the case of emergency can be very difficult. This is very problematic for senior citizens who are more prone to medical care. One way to provide for health related medical emergencies is by taking up health insurance plan. Health insurance offers huge help and flexibility when it comes to disease and ailment coverage. For example, some health insurance plans cover for more than 30 critical illness and over 80 surgical procedures.

With health insurance individual is assured of a more secure future, both health wise and money wise and this makes health insurance very important and critical for individuals and especially if they are responsible for the financial well being of the family.

There are several common reasons for medical claim denials. However, I would discuss about top reasons medical claims denied in this article and how we can avoid them.

6 Ways to avoid Health Insurance Claim rejection

The most critical and important time in the tenure of a health insurance policy is when an individual files for a claim. It always remains a matter of concern whether the insurer will give the insurance claim or not. It is human tendency to focus only on the price of the premiums or the tax benefits one can avail. We rarely scrutinize the features of the policy and its limitations and which becomes a major reason for a claim to be rejected. Instead of understanding health insurance claim denial reasons at later point of time, you can try to avoid them.

While taking a health insurance plan one need to be careful of a number of important aspects so that they ensure they would not get into a bad situation.

1) You or your family should fill claim form

To have the insurance form filled by the policy holder themselves so that the policy is not underwritten with incorrect details. The policyholder should also thoroughly check the policy documents before submitting them to the insurer to ensure that the information provided in it is correct and is not misrepresented because when it comes to filling up the form, we depend on the agent or hospital attendant to do it and sometimes they fill up wrong information in the form.

2) Read the conditions of Health Insurance Plan before you buy

Policy holders should read the terms and conditions of the policy thoroughly because in many conditions the policy holder don’t even know what features are included and excluded from the policy. Since policy terms and conditions are written in complicated manner policy holder should take out time to go through them thoroughly. Individuals should check online and review cases, which are rejected in the past and the reason behind the rejection.

3) Disclose all facts in Health Insurance Plan

I indicated earlier on this blog that my health insurance plan, I indicated clearly that I have asthma. I have been issued health insurance plan. Now, in future, if I am hospitalized due to asthma, the insurance company has to accept my claim and cannot reject. Policy holders should always disclose information accurately to the insurer so that later they claim does not get rejected. Policy holders should not hide their health history in terms of pre-existing medical illness or major disease.

4) Avoid unnecessary medical procedures / tests at the hospital

In many cases, medical centres perform procedures that may not be required by the patient, but in order to have more business these centres offer them, which is taken by the patient thinking that it will be covered in the medical claim. However, if these procedures are not in line with the medical history of the patient and is necessarily required during the course of their medication, there are many chances that the claim might be rejected. However, you may have limited say on this as if Doctor prescribes to know the advanced condition of the patient, we cannot argue with them.

Also Read: Best Medical Insurance Plans that comes with good features and low premiums

5) Go for cashless claims

Most health policies offered these days has a list of hospitals to provide cashless treatment. Policy holders should thoroughly scrutinize the list of hospitals mentioned in the policy to avoid discomfort in the case of the emergency. On the date of joining the hospital or put a claim, the hospital can get pre-approval for cashless claims. This way, your total amount required for medical treatment is approved and later when the final bill comes, the insurance company would not reject your claim.

6) Take a comprehensive health insurance plan

If you observe, there are several companies or banks who would offer a health insurance plan for low premiums. These contain several terms and conditions and would not be useful when required. Health insurance policies with low premiums should be avoided by individuals because agents and insurance companies in order to have a more business offer such schemes. These low premium packages do not cover incidental loses or loss of money in case of accident or critical medical emergency. As a result, due to low premium the full benefits of the policy cannot be redeemed.

Conclusion: Health Insurance Plan is good for secured life and healthy future. If you can consider these tips, you can avoid health insurance claim rejections.

Readers, any time your health insurance claim got rejected? How you managed the situation then?

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How to avoid health insurance claim rejections


  • Sudhir Bhatia

    Currently many Executives in Private Sector have good Medical Policies and thus these Executives are very comfortable while they are in Service.

    Once they are out of Service (for whatever reasons); they are left with no policy cover.

    If they purchase a Private Medical Policy during their service period while targeting the Policy Amount factoring Inflation and in their post retirement eras; the premium becomes very heavy even though both the Policy holder as well as Insurer knows that while these Executives are in service, they shall only be utilising their Employer provided medical cover. Thus no medical cover is purchased/can be gainfully purchased.

    The need being; current mediclaim policy providers should float policies wherein these Executives make (reasonable annual contributions) but they are eligible for medical cover only after the Specified 40th/50th/60th birthday of the policy holder.

  • vikas chand

    Most of medi claim companies try to denies insurance when one claims for settlement. Is it true sir….n one has to go through lot of work n tension for claim.As while taking health insurance policy companies show its best n harassment free claim settlement but in reality its vice versa. Sir please guide me so that I should opt for health insurance or not.

  • shekhar

    Dear Suresh ji

    can you write a blog on best health insurance plans in 2016yr.with full details.
    it will help me to chose best plans for me and my family.


  • marcus

    Compare Hospital Room Eligibility Capping

    Now this is the big one. This single condition could depreciate the value of your health insurance with inflation. Something most agents/insurers won’t like you to know.

    Many Health Insurance policies have room rent capping, which means you are eligible to claim expenses only up to a room costing below this capping. In case you opt for a room above this cap, you will have to bear the additional proportionate expenses on your own. Let me give you an example

    Lets say, as per your policy you are room rent limit is Rs 4,000 per day . Now if you get hospitalized and you choose a room (for if you are forced to choose) which has room rent of Rs 10,000 . You might think that you will just get 4,000 per day for room rent from insurance company and other charges you will get as per the limit. But thats not true.

    In reality, your room rent limit is 40% of the room rent chosen, hence all other expenses will be paid by 40% margin only. Means if your actual bill for ICU has been Rs 20,000 , and even if it’s in the limit, you will still be paid just 40% of 20,000 = Rs 8,000 .

    If your doctors bill comes to Rs 50,000 and even if it’s in the limit , still you will be paid only 40% of that, which is Rs 20,000 . So overall you will be at a big loss only because of the room rent capping limit.

    I hope you are now clear on the implications of the room chosen at the time of hospitalization.

  • Satish


    Nice article on health insurance,

    I am planning to purchase a policy from star health- Star health family optima floater for 5L SA, they have mentioned the room rent as 7500. If I go for the room rent above 7500 will all the medical expenses charged proportionately above the limit? I checked with the star health they say only room rent will be charged above the limit and rest of the medical expenses will be actual.
    Am not sure they are saying correctly?
    Pls clarify

    • Satish, The room rent limit is only applicable for rent. Remaining claims would be as per policy and not limited proportionately What you heard from Star Health is correct

      • amarjeet singh

        In all the hospitals in Delhi as the room rent increases the medical charges also increase and that very exponential rate. The OT charges for dormitary will will be different from twin sharing and from single room occupancy.I am speaking from my own experience and than TPA will only clear the claim for the lowest charges which they have mentioned in their brochure

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