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What To Do If Your Health Insurance Claim Get Rejected?

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How many times have you come across the scenario when your health insurance claim gets rejected by the insurance company? The answer could be many or at least one time. When your health insurance claim is refused, look for errors on the claim form. You can get your claim form repaired with the help of a third-party agent and proper documents. There might be a variety of reasons why your claim was denied in the first place. Some of the most prevalent explanations are as follows:

 

Why your claim get rejected?

Why your claim get rejected?

Some of the most prevalent explanations are as follows:

  • You made mistake while filling out the claim form or provided improper documents.
  • You provided inaccurate details while buying the policy.
  • You have claimed a treatment that is not included in the policy.
  • Your policy may have lapsed on non-Payment of premiums, hence it gets rejected, or maybe the insurer thinks your claim is unjustified. 

There are several reasons other than these for your claim rejection. The first step would be to check the information issued by the insurer and read all the clauses mentioned based on which the insurance company must have rejected your claim. You can also do the following checks to know the reason behind rejection. 

What are the options you have and what should you do?
 

What are the options you have and what should you do?

Check if you made any mistake in filling out the claim form and file the claim again with accurate data (if mistake found) and proper documentation. Try to give out all the documents that are being requested, and if needed, seek help from experts who can help you in filing a precise claim.

If your claim might be rejected because the insurance deemed it unwarranted, this might occur if the insurer believes a certain treatment or operation was unneeded. In this case, you can submit your doctor's diagnosis and prescription reports to justify the treatment and claim.

You can write a mail or send a letter, with a statement stating why the claim is legitimate or valid. Also, attach relevant documentation, as well as the licensed medical practitioner's medical opinion, to substantiate the allegation. All in all, you have to convince your insurer and explain the grounds on which your claim stands valid. 

Ombudsman's office

Ombudsman's office

If you believe you have acted in good faith and are not in the wrong, but your dispute with the insurer didn't get settled or the insurer didn't react to your claim with 30 days, you can approach Ombudsman and file a complaint. This organization allows you to file a formal complaint with the Office of Insurance Ombudsman within thirty days of receiving a response from your health insurer. 

The Ombudsman's office is your final resort for getting your claim approved. Beyond that, you may require legal assistance, which will usually cost you more than your medical expense. As a result, ensure that you have a valid claim and adequate supporting documentation. You can file at Ombudsman's office under various grounds such as a premium dispute, delay in claim settlements, misrepresentation of terms and conditions, etc.

Story first published: Wednesday, January 19, 2022, 2:35 [IST]
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