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How to appeal a denied health insurance claim in India


Why are health insurance claims denied?

Purchasing a health insurance plan is the best way to protect yourself and your loved ones from unexpected medical expenses, however, in rare cases, your insurance company may deny your insurance claim. An insurance company can deny a claim only on good grounds. Fortunately, you will have the option to reapply if your insurance claim is initially denied due to an error. Here are some reasons an insurance company may deny your health claim:

  • If you want to get health insurance for medical expenses that is not covered by your health insurance plan, your claim will be denied.
  • If you make a claim for health insurance or treatment under an expired policy, your claim will be rejected.
  • If you provide incorrect information on your insurance claim form, your insurance provider is more likely to deny your health claim.
  • If a health insurance claim is made to a person who is not insured under the policy, the insurance claim will be rejected.
  • If you submit incorrect documentation, such as incomplete hospital bills and records that do not match the amount of your insurance claim, your health insurance claim may be denied.

The first step to ensuring your claim is not denied is to read your insurance policy politicians document in detail to understand all conditions. Often, policyholders do not read the documents properly, which later leads to many problems regarding their claims. Reading them will help you avoid inadvertent mistakes when filing an insurance claim. Then double check that all the information you have filled in the insurance claim form is correct and all the attached documents are in order. Even minor mistakes in your claim form and documents can cause your insurance claim to be denied. If your insurance claim is still denied, there are steps you can take.

What to do if your insurance claim is denied

If the insurance company rejects your claim, they will tell you the reason for the rejection. If your claim has been denied due to errors in the form or documents, you can re-submit your insurance claim with the correct form and documents a second time. It is very important to understand the reason for the initial denial of your insurance claim, otherwise there is a high chance that your claim will be denied again. When re-submitting a claim, make sure you keep copies of emailed correspondence with the insurer for proof.

However, it is important to note that if your insurance claim has been rejected due to expiry of the policy, your claim will not be accepted under any circumstances. If you re-apply for an insurance claim and your insurer continues to reject your insurance claim without good reason, you can contact the insurance ombudsman.

Appeal to the insurance ombudsman

The insurance ombudsman is the last resort or last resort that policyholders can turn to when their insurance claim has been denied time and time again. To protect the interests of policyholders and enable them to settle their claims fairly and transparently, the Government of India has created the post of Insurance Ombudsman. You can submit a written complaint to the Insurance Ombudsman with details of your rejected insurance claim and information about your insurance provider. The insurance ombudsman will review your case and mediate between you (the insured) and your insurance provider. The ombudsman will also give unbiased recommendation to the insurance company to settle claims if they are at fault. However, if the ombudsman finds that the insurance company is correct in rejecting the claim for good reason, your claim will remain rejected.

First of all, it’s also important to make sure you don’t make any mistakes when you first apply. At that time buying a health insurance plan, you should make sure that all the medical conditions and illnesses that you need are included in the policy, as well as any other types of inclusions that you think you might need in the future. More importantly, look for an insurance plan that offers a cashless hospital network. With cashless health insurance, you can visit a network hospital directly in case of a medical emergency. Be well informed healthcare system of this hospital. The network hospital will quickly verify your insurance information and the insured’s treatment will begin. You won’t have to pay the bills as the insurer will pay the sickness benefits directly, reducing the chances of your claim being rejected to almost zero.

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