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Terms and conditions
Terms and conditions
The main reason that most people purchase a health insurance policy is for financial security and peace of mind during medical emergencies.
But, after going through a stressful medical procedure, or recovering from an illness, the last thing you need is to have your health insurance claim rejected. Unfortunately, this could be a possibility in case there is a mistake in the claims process.
However, did you know that you can appeal this decision, and ask your insurance company to approve your claim even after rejection? Here is how:
Even after a health insurance claim has been rejected, you can ask your health insurance company to reconsider it. To do so, you need to convince them that your claim is 100% genuine. First, you need to know it was rejected, and then you can proceed by following these steps:
The first thing you should do is look for the reason your claim was rejected, as only once you know the reason, can you try to rectify it.
Insurers might reject claims due to issues with the bills or documents, so check for any errors in your submitted claim form, or any mistakes in the documents you submitted. Another reason might be that the insurer might feel that your hospitalization was unwarranted.
However, if the reason was that you had not cleared your waiting period, or your policy had expired, be advised that your claim will not be eligible.
If you think you have a reason to reapply for the rejected claim, you need to get in touch with your insurance company and the third-party representative or TPA to inform them about reinitiating the claim.
You can challenge the claim related dispute over call or email. It is recommended to have a written email to have proof of your communications. It is also important to contact the hospital as well and mention the details for enquiry.
Based on the reason that your claim was rejected, you might need to correct some information:
You can reach out to a representative of the insurance company, or get the help of your TPA representative to reopen your case and have your claim form and documents corrected.
Once you have got together all the documents, facts, and any additional information to support your claim, here’s what you must do:
Remember that you can make multiple appeals for claim validation.
If you don’t get a response from your health insurer within 30 days proceed to Step 5.
If you are unhappy with the resolution provided by your insurer you can, approach the nearest Ombudsman office within 30 days of your health insurer’s response.
The Ombudsman will act as a mediator and will arrive at a recommendation concerning your appeal against the insurer’s decision.
In more extreme cases, if you are also unhappy with the Ombudsman, then as a last resort you may file a case with the consumer court. However, keep in mind that this might require legal aid which might end up costing more than your medical bills, and will also be time-consuming.
While having a health insurance is essential, it is also important to know that it comes with certain terms and conditions. Thus there are some factors that might lead to health insurance claim rejection, such as the following:
As the saying goes, “prevention is better than cure”. And so it is important to know what preventive measures you can take to ensure that your health insurance claims are not rejected.
If you file a health insurance claim and it gets rejected, it can be a very stressful time. Hence, it is good to know that there are methods that you can use your claim is rejected. However, it is always better to try and avoid rejection than to take these remedial measures after the fact.
Try to make sure not to give your insurer a reason to reject your claim, and always renew your health insurance policy on time so that it is active, and you can file a claim during any medical emergency.
The documents you need will depend on the kind of claim you make. For Cashless Claims, you just need to fill in the required form given by the TPA at the hospital. On the other hand, for a Reimbursement Claim, you will need to submit your health invoices, including medical bills, doctor’s prescriptions, etc.
The documents you need will depend on the kind of claim you make. For Cashless Claims, you just need to fill in the required form given by the TPA at the hospital. On the other hand, for a Reimbursement Claim, you will need to submit your health invoices, including medical bills, doctor’s prescriptions, etc.
If a claim is filed before the completion of the initial waiting period, it will be denied by the insurance company, except in the case of accidental hospitalization.
If a claim is filed before the completion of the initial waiting period, it will be denied by the insurance company, except in the case of accidental hospitalization.
While the IRDAI’s Health Insurance Regulations 2013 say that your health insurance premium can’t be changed for at least the initial 3 years, post this period, our premium can increase upon renewal. One of the reasons for this increase could be a recent history of claims for surgeries, serious illness, or other medical issues.
While the IRDAI’s Health Insurance Regulations 2013 say that your health insurance premium can’t be changed for at least the initial 3 years, post this period, our premium can increase upon renewal. One of the reasons for this increase could be a recent history of claims for surgeries, serious illness, or other medical issues.
Yes, you can if it is a daycare procedure or an OPD – provided that you’ve opted for an OPD cover in your health insurance.
Yes, you can if it is a daycare procedure or an OPD – provided that you’ve opted for an OPD cover in your health insurance.
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Disclaimer #1: *Customer can choose options at the time of availing insurance. Premium amount may vary accordingly. Insured is required to disclose any pre-existing condition or on going treatment before policy issuance in the proposal form.
Disclaimer #2: This information is added only for informative purposes and collected from different sources across the Internet. Digit Insurance is not promoting or recommending anything here. Please verify the information before making any decisions.
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closeAuthor: Team Digit
Last updated: 02-07-2024
CIN: U66010PN2016PLC167410, IRDAI Reg. No. 158.
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