4 min read

This is Why Your Health Insurance Claim Was Rejected!

They say you should expect the unexpected. It’s all fun and games until things get personal. And that’s why we all buy insurance! The obvious first instinct is to prepare for the worst. 

Unfortunately, despite having health insurance, there may come a time when you are taken by surprise! Scratching your head, pacing down corridors, talking to IVRs – in search of the elephant in the room: Why was my insurance claim rejected when I did everything right? 

There can be multiple reasons. Here’s a detailed understanding of the different scenarios in which your health insurance claim can be rejected. 

  1. You lied about something–knowingly or unknowingly

The insurer will conduct a background check when you buy an insurance policy. This includes personal information about your age, gender, family members etc. Your medical history matters a lot. If you already have medical ailments, especially critical ailments, getting insurance will be an uphill task for you. If you have lied about your pre-existing diseases (PED), age, or any information, the insurer has the right to reject your claim.

In extreme cases, the insurer can completely cancel your health insurance policy

  1. Your timing wasn’t right

Filing a claim during the waiting period will mostly be rejected. 

Your health insurance policy (even group health insurance policy) will have a waiting period for PED. It refers to any pre-existing diseases that you may have at the time of buying insurance. 

There are different durations of a waiting period.

Waiting Period What is it for?
Up to 30 days Accidents
Up to two years All illnesses specified by the insurer
Up to three years PED (differs from insurer to insurer)

  1. It’s not you. It’s your hospital.

Insurers operate on an intricate network of hospitals—a list of hospitals where your health insurance e-card is accepted. Each insurance company has a set network hospital and a list of blacklisted hospitals!

If your insurer has blacklisted the hospital where you’ve completed the treatment, there’s a negligible chance of your claim being processed.

What is a blacklisted hospital?

When a hospital overcharges patients, give false quotes or indulges in any other corrupt activities, insurance companies blacklist it. And rightly so! There have been many instances where hospitals have given a bill with an unfair price.
Before entering a hospital, check the network hospital list or call your insurer to verify the hospital's credibility. 

  1. Your insurer has put their foot down!

Insurance is a tricky business. You must always read and understand the fine print thoroughly. Every insurance company has permanent exclusions. These are treatments the insurer will never cover. For example, suppose your family has a history of cancer. In that case, cancer treatments will likely be added as an exclusion.

Fact: If you are a chain smoker, the insurer may exclude cancer treatments from your policy.

  1. Partial Acceptance

What if your claim is rejected partially? Insurers exclude consumables—medical items such as PPE kits, masks, gloves, and crepe bandages—that can be discarded after use.
If your claim amount includes the cost of consumables, the insurer will likely settle the claim partially. 

Insurance is tricky. Stay informed & read the fine print multiple times because you can fall into an insurance scam very easily. If you have any questions about insurance, talk to us. We will help you out.   

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