Why Your Cashless Health Insurance Claim Could Be Denied?

A health insurance plan is a mandatory requirement these days just like food, shelter and cloth. Since a feature-laden health insurance plan provides you with financial coverage to you during a medical emergency, it lets you save on the health care payments.

As per a study, it is estimated that around 85% rural and 80% urban population is still not covered under any health insurance plan.

While there may be many reasons for people not availing these insurance coverages, one of them is not knowing how the claim is processed and alike aspects.

Further, the fear of the claim rejection is another pivotal reason keeping them off to buy health insurance schemes.   

These fears are myths and need to be debunked. While it’s true that at times, claims get rejected, but only when there is a genuine reason behind it. This post will shed some insights on why your cashless claim could be denied and how to correct it.

  • Misrepresentation of material facts

Before the payment of the hospital treatment, the insurance company takes some time in verifying the same. At any point, if they see a misrepresentation of the fact, they reject the claim directly. Even a simple mistake of overlooking of facts may be enough for you to land a rejection. Thus, what you can do is – always ensure to fill a claim form with the utmost care and provide all relevant details which you can prove in writing.

  • Incorrect claim procedure

The filling of the claim form and filling out the details is the standard procedure followed by standard health insurance providers. However, it may not be the same for all. Yes, the exact procedure of the claim settlement may vary from insurer to insurer. Not following a procedure of how an insurance company will settle a claim may see a rejection. Thus, make sure you follow the standard health insurance claim procedure while making a claim.

  • When you ask for claims for permanent exclusions

You need to know that there will always be some diseases or illnesses that won’t be considered as exclusions. Thus, you may need to note the exclusions in the health insurance policy. If you are admitted to a hospital for a treatment which is not covered by your health insurance policy and asks for a claim, it may be rejected. Some of the common exclusions in a standard health insurance policy are:

  • Any illness that you may have taken by war or similar grounds
  • Directly or indirectly contracting sexual diseases or illnesses caused by HIV
  • Treatments that you may be taking to alter pregnancy
  • Fertility treatments
  • Treatments availed from an authorized or unlicensed physician
  • Obesity
  • Injuries inflicted by self
  • Cosmetic or dental treatments
  • Congenital diseases
  • Alternative or Ayurvedic treatments

Some of the treatments that are considered as temporary exclusions in a health insurance policy are:

  • Any claim of the health insurance for 30 days from the starting of the scheme, except for injuries inflicted from an accident
  • Pre-existing diseases have a waiting period of 1-6 years and may differ from company to company
  • Ailments such as a hernia are covered in a health insurance policy but only after a waiting period of up to 2 years

The Bottom Line

There are many reasons that may see the cashless medical insurance rejection handed out to you. Now that you know some of the situations in which a cashless medical insurance claim may be denied, you can now apply for a claim with care.   

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