Reasons Why Your Health Insurance Claim Could be Rejected

Imagine being admitted to a multi-speciality hospital for an operation, knowing that your health insurance plan will cover you financially. But, after making a claim, you got to know that your insurer rejected medical claims!

Scary right? Well, it can happen. In 2018, the hospitals in Dubai saw an almost 14% rejection rate from the insurers that wreak havoc on policyholders.

While it may seem surprising, it can happen in certain circumstances. If you want to avoid such incidents, first, you need to know what leads to such rejections in the first place!

The above plans and premiums are for AED 1,000,000 Sum insured for 1 Adult of 30 Years for Dubai city.

Reasons why health insurance claim is rejected

Following are some of the common reasons that can get your health insurance claims rejected:

Policy lapse

A health insurance plan comes with an expiry date; you need to renew it before that to continue enjoying its benefits. Now, it is often a common practice to be lacklustre about renewing the plan. In comparison, you should have done it on or before the plan expiry date.

If you file a claim during this phase, where the insurance plan is not active due to non-renewal, your claim will face rejection.

Therefore, it is advised that you should not delay even for a day to renew your health insurance dubai plan. Ideally, you should do it before the expiry date. Otherwise, you have to face the consequences of rejected medical claims.

Wrong information

Another health insurance company claims rejection reason is discrepancies in the information provided. It can be a genuine mistake to mention the wrong spelling of names, date of birth, and likes. Sometimes, people also intentionally provide wrong information, especially about their ages and income.

Since the sum insured depends on the income, people try to hide their real income to get a higher sum insured. In such cases, the insurer may reject a medical claim if they find false information about the policyholder.

Ignoring the exclusions

Very few people read the fine print of a health insurance plan before purchasing one. However, it contains all the exclusions and terms and conditions of the plan. For instance, most health insurance plans have a 30-day waiting period (not applicable for accidents). It means you must wait 30 days before claiming to purchase a health insurance plan.

In other cases, your plan may not cover treatment for pre-existing illness or any claim against an accident caused due to adventure sports, intoxications, etc. If you claim a reimbursement in any of these cases, most likely, you will find your insurance claim rejected.

Pre-existing illness

Most health insurance plans do not primarily cover treatments for any pre-existing illness such as high blood sugar, heart disease, etc. It means any claims made against such treatments will result in an insurance company rejected claim.

This rule prevents people from buying a health insurance plan only to cover the hospitalisation cost for an existing ailment.

Exceeding sum insured

Whether you choose individual health insurance or a family floater, a pre-specified sum is applicable for a year. It means you can avail of cashless treatment up to that limit only. Now, if you already claimed that amount, your claim will not be approved for the second time that year.

In case you have a previous claim of less than the sum insured, you can claim the rest of it. However, in that case, the insurer may offer reimbursement and not a cashless facility.

It depends on the terms and conditions of the insurer you choose.

Delayed claim application

Insurers give you a certain period to claim health insurance. Generally, it is 60 to 90 days from the date of discharge from the hospital. Any delay in making a claim can result in rejected medical claims.

Therefore, it is better to ask your insurer about the claim procedure and the time limit for the same to avoid any confusion later.

However, once your medical claims are rejected, you can do the following –

Try to find out what made your claim rejected.

If you think it is rejected unduly, get in touch with your insurer, TPA and respective hospital with proofs and necessary documents.
Consult the TPA representative after making necessary changes in forms to reopen the case.
File a claim again and wait for about 30 days.
If you are unhappy or do not get any response from the insurer’s end, contact the nearest Ombudsman Office for further procedure.

Your case will be resolved soon if you have proper documents and proof and care claimed as per the insurer’s policy.

Conclusion

Rejected medical claims are the last thing you want when undergoing necessary treatment or meeting an accident. Hence, you must remember these things while purchasing a health insurance plan and making any claim. It will avoid any last-minute confusion and ensure a hassle-free claim process. Moreover, do not forget to read the terms of a policy before signing the agreement.