A practical guide to ensure your health insurance works when you need it most.
You diligently pay your health insurance premiums every year, believing you have secured your family's financial future against medical emergencies. But when the time comes to make a claim, you receive a notification from the insurer: "Your claim has been rejected." This is the single biggest fear for every policyholder, and unfortunately, it's a reality for many.
However, most claim rejections are not arbitrary. They are usually based on specific terms and conditions in the policy document that the policyholder may have overlooked. The good news is that a majority of these rejections are entirely avoidable. This guide will break down the top reasons why health insurance claims are rejected and provide you with a clear, actionable checklist to ensure your claim is processed smoothly.
Understanding these common pitfalls is the key to a successful claim.
The Problem: This is the number one reason for claim rejections. When filling the proposal form, if you deliberately hide a medical condition you already have (like diabetes, high blood pressure, or a past surgery), the insurance company can reject your claim later, citing non-disclosure of material facts.
How to Avoid It: Be 100% honest on your proposal form. Disclose every single health condition, no matter how minor you think it is. The insurer might charge a slightly higher premium or impose a longer waiting period for that disease, but your policy will be secure, and your claims will be honored.
The Problem: Health insurance policies do not cover everything from day one. They have waiting periods. If you claim for a condition during its specific waiting period, the claim will be rejected.
How to Avoid It: Understand the three main types of waiting periods in your policy:
The Problem: Every policy has a list of "exclusions" – treatments that are not covered. Common exclusions include cosmetic surgery, dental treatments (unless caused by an accident), and self-inflicted injuries. Claiming for an excluded procedure will lead to rejection.
How to Avoid It: Carefully read the "Exclusions" section of your policy document. Use the 15-day "free-look period" after purchase to go through this list. If you are not happy with the exclusions, you can cancel the policy for a full refund during this period.
The Problem: This is a simple but common mistake. If you fail to pay your renewal premium on time and the grace period has passed, your policy lapses. Any claim made during this lapsed period will be rejected.
How to Avoid It: Always pay your premiums before the due date. Set up reminders or an auto-debit instruction from your bank account to ensure you never miss a payment.
The Problem: Insurance companies require you to follow a specific process. For planned hospitalizations, you must inform the insurer in advance. For emergencies, you must inform them within 24-48 hours of admission. Failure to do so, or submitting incomplete documents, can lead to rejection.
How to Avoid It: Read the claim process mentioned in your policy. For cashless claims, ensure the hospital submits all documents correctly. For reimbursement claims, keep all original bills, reports, and discharge summaries safe and submit them on time.
If you believe your claim has been unfairly rejected, you have the right to appeal. The first step is to contact the insurance company's own Grievance Redressal Officer. If you are not satisfied with their decision, you can escalate the matter to the **Insurance Ombudsman**, an independent body that resolves disputes between insurers and policyholders. You can find more information on the official website of the IRDAI (Insurance Regulatory and Development Authority of India).