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What to do if your health insurance claim is rejected

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Imagine this scenario: you have been paying your premiums towards health insurance, month after month, and you made a claim for a particular healthcare treatment you received. However, the insurance company (or the TPA, if one is involved) gets back to you saying that your claim has been rejected. Would you be frustrated? Without a doubt, and rightfully so! You have been regularly investing your money in the health insurance company for the very purpose that, when you have a medical need/emergency, you will not have to run about for the money. If the insurance company rejects your claim in such a situation, it will be stressful for you – both emotionally and financially. We hope that you never have to go through such a situation, but we would like you to be prepared in case the need arises.

There are 3 major factors that affect the fate of a claim. They are:

  • The medical necessity of the treatment
  • The correctness of the details filled in the claim
  • The inclusion/exclusion of certain healthcare procedures as part of the policy

Here are a few steps to consider if you are ever faced with a health insurance claim rejection.

1. Question yourself

Everybody makes mistakes and, in this case, it could have been the insurance company or it could have been you. Before you go about taking any kind of action in response to the claim rejection, ask yourself these questions to find out if there has been a mistake at your end.

With regard to your eligibility in the purview of the policy:

  • Did you have a pre-existing disease that you did not disclose to the insurance company while purchasing the policy?
  • Was there a waiting period for pre-existing diseases that you may or may not have notified to the insurance company about? Was your recent hospitalisation connected to this pre-existing disease?
  • Was your claim for a cosmetic surgery or some other non-curative treatment? If it was a dental treatment, is it something covered by your policy?
  • Was the hospitalisation only for diagnostic purposes and not for actual treatment?
  • Did you inflict injury on yourself – such as a suicide attempt or a condition caused by your drinking or smoking habit?
  • Was the treatment you availed related to any other permanent exclusions mentioned in the policy document? These could be congenital or genetic diseases, injury during war, etc.

With regard to your claim:

  • Did you submit the adequate documents as required?
  • Did you make the claim in a timely manner? Most claims need to be made within a certain number of days/weeks after the hospitalisation.
  • Did you make your claim during a waiting period?
  • Has the date of your insurance cover expired or has the sum insured been exhausted?
  • Did your claim exceed the permitted sub-limit applicable for the particular treatment?

Once you ask yourself the above questions, you will know (more or less) if the claim was rejected because of an error at your end. However, if you are convinced that you have done everything right, then you can proceed to investigate further.

2. Read the adjudication report

The insurance company is required to state a valid reason for the rejection of your claim. In the case of a cashless claim, this report is sent to the hospital and in case of a reimbursement claim, it will be sent directly to you.

Reading through this report may give you answers and help you take the next steps.

  • Sometimes, there may have been an error in the way the form was filled. If it is something that can be rectified (such as a spelling error or a customer number error), you can inform the TPA with a request to reopen the case and/or reapply once again.
  • If your claim was rejected due to insufficient proof/documentation, then you can reapply after checking and collecting the required documents. You may need to make a few trips to the hospital for these, if you don’t have them already. Sometimes, you may have simply forgotten to attest a document, and this could have caused the rejection. In case of this and the previous scenario, remember to reapply before the window period for submission expires.
  • If the reason for rejection was that the treatment you availed didn’t seem necessary to the insurance company, go back to your doctor and collect a letter explaining why the treatment was necessary at that point. To strengthen your argument, you may also meet another doctor (who did not treat you for this) and get him/her to vouch for the validity of the treatment as well.

3. Contact the TPA/insurance company

It is highly probable that a claim was rejected due to an error from the insurance company’s side. If you have a valid argument and adequate proof, then you can get in touch with the TPA or insurance company and request them to reconsider your claim. Here’s how you can do it:

  • Write a formal letter/email with a clear title and a clear, understandable statement that validates your claim.
  • Attach appropriate documents (along with letters from doctors) with their medical opinion on why the treatment was necessary.
  • Await a response from the insurance company. However, if you do not receive a timely response, you may escalate the issue with a higher authority of the insurance company.

If your reasons seem valid, chances are that your claim will be accepted (either fully or partially) at this point. Ensure that you maintain a copy of every communication that has transpired between you and the TPA or insurance company regarding this case.

According to an article by Forbes, it is perfectly acceptable to re-apply the claim and/or appeal for the claim as many times as you want. Sometimes, if you give up too soon, you may lose out on what you rightfully deserve – especially if the insurance company is not genuine and is rejecting your claim simply to make a profit.

4. Seek a lawyer’s help

If none of the above work out and you are still fully convinced of the validity of your claim, make an appeal opposing the insurance company’s decision with the help of a lawyer. Remember that this is the last straw, and that you may be wasting your time, money and energy if your appeal is made against a valid rejection by the insurance company.

While making an appeal, make sure you have a copy of all the relevant documents with you – starting from hospital bills to all the communications (including emails) made regarding the claim between you and the TPA/insurance company. If your appeal has been found valid, you will be rightly rewarded by the approval of your claim.

 

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