What to Do When Your Health Insurance Claim is Denied?

Dealing with denied health insurance claims can be stressful. Reasons for denial include moratorium period, expired policy claims. Options to address denial: understand reason, make corrections, contact insurance provider, seek Ombudsman assistance, write appeal letter with medical documentation.

Health Insurance Claim is Denied.

Managing a medical condition can be difficult for the ill and their loved ones. Knowing that your health insurance will pay for the necessary treatments can be comforting. But what happens if your health insurance denies your claim? It could result in extreme stress.

Rejections of health insurance claims are real scenarios, and there are several reasons why insurers choose not to approve the claim. When insurance companies reject a claim, they usually notify the applicant and explain the reason. You shouldn't give up if the insurance company denies your claim. You have the option to reapply after appealing the denied claim application. So, let's discuss what to do if your health insurance claim is rejected:

Reasons for Health Insurance Claim Rejection

You need to be aware of the precise reason for the claim denial before you can pursue an appeal. The insurance companies typically deny applications for claims for the following reasons:

• You have raised a claim for a condition or course of treatment that the policy does not cover.
• The term of your policy has ended. 
• You haven't completed the application form with the information needed to support your claims.
• You have not submitted the necessary documentation or proof.
• You have submitted a claim for someone not covered by the insurance.

Steps to be Taken in Case Your Policy Gets Rejected

The IRDA of India has given a recent circular that any insurance provider may raise questions about health insurance claims following a policyholder's average of five years of premium payments—a time known as the moratorium period.

For the others, you'll need to speak with your health insurance provider and inquire why your claim was turned down. If you understand why, you can reapply the claim by doing the following:

1. Rectifying & Reapplying

You can make the necessary corrections and resubmit after you know the reason. Nonetheless, the claim will never be approved if the denial was due to a "claim raised for expired policy" or other similar reasons. 

Speak with an ACKO executive to determine why you were rejected and how to address the situation. You can do the same thing via email or phone. In such communication, it is preferable to have a written mail.

1. Approach An Ombudsman

An Ombudsman is a representative the insurance provider chooses to assist policyholders with grievances against them. The 1938 Insurance Act states that you can file a complaint with an ombudsperson regarding issues with claim settlement, premium discrepancies, unclear policy terms, or policy violations.

The Ombudsman serves as a mediator to assist the policyholder and the insurance company resolve their differences. The Ombudsman confirms the details and offers a reasonable suggestion.

Ensure you tactfully preserve all the bills to strengthen your claim when you speak with the Ombudsman. Copies of the payment receipts, KYC, and policy documents are preferable.

1. Write An Appeal Letter To Your Insurance Company

Writing an appeal letter to the company with the necessary information is one of the simplest ways to file an appeal against a denied health insurance claim. The email or letter should include all pertinent information, including the reason for writing it.

Along with mentioning your medical condition, you must also explain why you took advantage of this policy. Include documentation of your doctor's medications and the recommended course of therapy. It will assist the insurance company in reevaluating your appeal of the denied claim.

Conclusion

Rejection of insurance claims can happen, but there's no reason to panic. So, for best results, make the required adjustments before submitting your claim after taking the time to comprehend why it was rejected. The insurer will probably evaluate your appeal favourably and eventually approve your claim if it is valid.

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