ealth insurance is meant to provide financial security during medical emergencies. However, many investors and policyholders experience frustration when their claims get denied. Since the primary reason for purchasing health insurance is to get financial support when needed, facing difficulties during claim settlement can be both discouraging and financially draining. Investors are often unaware of the hidden policy terms and unexpected exclusions that can lead to claim rejection. That's where a health insurance agent in Chennai like Fairmoves can help you avoid getting into this kind of situation. Let's learn the common reasons behind claim denials, and learning how to avoid them can save you from unnecessary stress.
1. Incorrect Information
Providing inaccurate information while purchasing a health insurance policy can lead to claim rejection. Some key details that must be correct include:
Age
Income
Existing medical conditions
Medical History
Profession (especially if high-risk)
Hobbies (such as adventure sports)
To avoid this issue, fill out the application form yourself instead of relying on an agent. Make sure all the details are truthful and accurate.
2. Non-Disclosure of Pre-Existing Diseases Lifestyle Habits
Hiding pre-existing diseases or lifestyle habits like smoking and drinking alcohol can result in claim rejection. Insurance companies assess risk based on these factors. If undisclosed, the insurer may refuse the claim. Always be transparent about your medical history and habits when applying for insurance.
3. Making a Claim During the Waiting Period
Every health insurance policy comes with specific waiting periods, such as:
30-day waiting period: Except for accident-related claims.
Maternity waiting period: Usually 24-36 months.
Pre-existing disease waiting period: Typically 24-48 months.
Critical illness waiting period: Usually 90 days from policy issuance.
Read your policy document to understand these waiting periods before making a claim.
4. Seeking Treatment at a Non-Network Hospital
If you choose a non-network hospital, your cashless claim might get denied. Before hospitalization, check if the hospital is part of your insurer’s network. If not, you will have to pay upfront and later apply for reimbursement. Keeping a list of nearby network hospitals handy can be beneficial in emergencies.
5. Claiming Services Not Covered Under the Policy
Some treatments and services may not be covered under your health insurance policy, such as:
Dental treatment
AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) treatments
Outpatient department (OPD) services
Maternity expenses
Review your policy document to understand what is included and excluded before making a claim. If a certain treatment is essential for you, consider opting for add-ons that provide additional coverage.
6. Policy Exclusions
Some treatments are standard exclusions in most health insurance policies. These typically include:
Cosmetic or plastic surgery
Gender transition treatments
Injuries from adventure sports or illegal activities
Treatment for substance abuse or alcoholism
Fertility and sterilization expenses
Insurance providers include these exclusions to manage risks effectively. Before purchasing a policy, go through the exclusions section carefully to avoid unexpected denials in the future.
7. Claiming Under a Lapsed Policy
If your health insurance policy lapses due to non-payment of renewal premiums, your claim will be rejected. To avoid this, renew your policy on time. That's where the best health insurance agency in Chennai can set up auto-debit for premium payments to help you avoid missing deadlines. A lapsed policy means losing all accumulated benefits, including waiting period credits.
8. Claim Amount Exceeding Sum Insured
Each health insurance policy has a maximum coverage amount, known as the sum insured. If your claim amount exceeds this limit, the insurer will only approve up to the available sum insured. To stay financially protected, consider increasing your coverage periodically. Additionally, top-up or super top-up plans can provide extended coverage without high premium costs.
9. Delay in Informing the Insurance Company
Not informing the insurer about hospitalization within the stipulated time can result in claim rejection. For planned treatments, inform the insurer in advance. In case of emergencies, notify them within 24-48 hours as per policy guidelines. Timely communication helps the insurer process the claim smoothly without unnecessary delays.
10. Incorrect Documentation
Submitting incomplete or incorrect documents can lead to claim rejection. Always provide the necessary paperwork, including:
Hospital bills and invoices
Doctor’s prescription
Test reports
Policy details
Ensure all documents are correctly filled out and signed before submitting them. Keeping digital copies can be helpful in case of loss or damage.
Smooth Claim Approval Process
To minimize the risk of claim denial, follow these best practices:
Fill out the health insurance application form accurately.
Disclose all medical conditions and lifestyle habits truthfully.
Understand policy waiting periods and exclusions.
Seek treatment at network hospitals for cashless claims.
Renew your policy on time to avoid lapses.
Inform your insurer promptly about hospitalizations.
Get all relevant documents ready for claim submission.
Conclusion:
By following these guidelines, you can get a hassle-free claim process and make the most of your health insurance coverage. Understanding health insurance policies and being proactive about compliance can save you from stressful claim denials. Stay informed, choose the right plan, and work with experts to secure a smooth health insurance experience.
