How You Can Appeal Against Denial Of Medical Insurance Claim

Coping with health problems is difficult not only for the patient but also for the family. In such a scenario, the health insurance buffer comes into play as a support system. However, denied health insurance claims can lead to serious harm. Yes, your health insurance company can deny your claim. However, you have the option to appeal a rejected claim. Before that, you need to understand claim rejection and why it happens.

What can be the reason for claim rejection? 

Every company that sells health insurance in India has a different set of strong reasons for denying health insurance claims. In many cases, the reason for rejection is communicated while rejecting the claim request. Otherwise, the policyholder can ask the provider for the reason. Once the reason is known, you can make corrections (if possible) and reapply.

After receiving the claim request, the first step that the claims team takes is to check the applicant's policy details. This verification includes basic details like names of people covered, inclusions, policy validity, etc. Here is a list of the most important problems faced by the claims team that lead to claim rejections.

• A claim has been filed for an issue not covered by this policy

• The claim has been made on an expired policy. 

• The application form does not contain the required details

• You did not provide supporting documents

• A claim was filed on behalf of someone outside the scope of the policy

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Fix and reapply

Once you know the reason for rejection, you can rectify it (if possible) and resubmit your claim. But if the reason for rejecting the claim is an "expired policy claim" or similar, you cannot expect an insurance claim acceptance. It may not help you to resubmit your claim either. Be sure to contact the manager of your insurance company to know the reason for the rejection and how to fix it. You can do the same by phone or email. For such communications, it is good to have written email proof. * Standard T&C Apply

Approaching the Ombudsman 

The Government of India has established an Insurance Ombudsman to help policyholders in the redressal of grievances. You can complain about your insurance company by writing to the Ombudsman in your area. Complaints may relate to the late settlement of claims, premium disputes, misrepresentation of terms and conditions, and other matters related to the Insurance Act of 1938.

The ombudsman's approach is an impartial and out-of-court system. In the event of a complaint, the ombudsman acts as an intermediary between the policyholder and the insurer and provides unbiased recommendations based on the available facts. *

Preventative efforts

It is better to read and understand the terms and conditions of the insurance policy before purchasing the insurance policy and filing a claim, instead of suffering the consequences of buying the wrong policy or filing a wrong claim. This is one way. A proactive approach to buying individual or family health insurance is to analyse your needs and buy a policy that covers those needs. Policy inclusions and exclusions are clearly stated in the policy document. *

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Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.