Health insurance claim appeal

  Getting health insurance is an ideal way to deal with the issues of health, hospitalisation and the emotional trauma that goes with it not only for self-help but also for the benefit of family members. A proper health insurance provides support financially and brings stability to life. However, in some cases insurance companies do reject insurance claims which can lead to mental and financial hardship. So, how can you cope with it. You have an option to appeal against a rejected claim.

Reasons to claim rejection

Insurance companies can reject a plan claim due to several reasons. As a policyholder you can request to know the reason for the claim and make amends or reapply. The first step performed by the insurance claims team after receiving a claim application is to look and check for the policy plan details of the insurer. All the basic details such as names, identification, policy validity, and inclusions are thoroughly checked and verified. Let’s take a look at what the reasons for claim rejection can be;
  • The claim raised for the treatment is not covered under the policy
  • The claim is raised in case of an expired policy
  • The insurer has made a fraudulent claim
  • The policyholder did not provide the required supporting documents to support the claim
  • The policyholder has not followed the entire process correctly
  • The claim is raised for someone who is out of the policy’s purview

Appealing against rejected claim

So, as your claim is rejected and you have understood the reason, why, you can appeal against a rejected insurance claim with the below mentioned important steps;

Check your claim form, rectify and reapply

If your insurance claim gets rejected, you should go through the denial letter and know the reason for rejection. If the insurance provider states a discrepancy in the claim form, you must review the application and rectify the errors to apply again. Ensure that you carefully go through the policy terms and conditions and re-apply within the period specified by the insurance company.

Approach an ombudsman

The Government of India created the Insurance Ombudsman to help policyholders to settle issues or complaints. You can approach the Ombudsman to raise a complaint against your insurance provider mentioning all the details of claim rejection. The complaint can be about delay in claim settlement, premium dispute, misrepresentation of terms and conditions, or other issues with respect to Insurance Act, 1938. Ombudsman is an official who investigates complaints lodged by private citizens against public entities and officials. The Ombudsman approach is an impartial and an out of court system. The Ombudsman acts as a mediator between the policyholder and the insurer in case of a complaint and arrives at a fair recommendation based on the facts available in the health insurance sector.

Provide sufficient documents and meet the necessary requirements

Make sure you understand the terms and conditions of a policy before purchasing it and raising a claim for it. Analyse your requirements and buy a policy knowing its inclusions and exclusions clearly. Always submit all the relevant documents to the policy. Suppose the reason for claim denial is insufficient proof to support the claim amount. In that case, you must collect all the bills and other related documents and provide as evidence when you file an appeal against the rejection.

Utilize communication

When you appeal against the denied health insurance claim, you must keep a record of the communication through email or messages you may have had with the insurance provider. This may act as proof to support your claim. So, make sure that you always keep the records safe to be used during critical situations like appealing for a rejected claim.

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