What to do if your claim from mediclaim policy is rejected?

Insurance

oi-Sunil

By Sunil Fernandes

Published: Thursday, February 27, 2014, 9:11 [IST]

Most of the times, amidst having taken a health insurance policies from reputed companies, we end up paying from our pockets. Ignorance is the major cause for us to put ourselves in this situation. Well, you have a policy, spent majorly on an illness but your claim is rejected.

I know how frustrated it would have been for you. Ok, what can be done in this situation? Is there a way to get your claim accepted and you get your spending reimbursed?
Read on...

1. Understand the reason for your claim rejection:

The ailments that are covered in the policy - Remember, you take an Insurance Policy as a backup for your medical expenditure. Please be clear about the day care procedures, OPD covers, hospitalization, diagnostic procedures and difference between classifications. Make sure that you understand what all ailments are covered in your policy and in which category these are grouped.

Read the rejection letter carefully - Don't be baffled if your insurance claim is rejected. Read the rejection letter

carefully and understand the reasons quoted for rejecting the claim. The reasons can vary e.g. ailment not covered, hospital is not a network hospital / coverage terminated, prior authorization requirements, incomplete documentation etc. Understand the reason why your claim is rejected.

If you are not convinced with the reason stated or with the claim rejection, contact your agent for better understanding.

2. Is your claim form appropriately filled?

Understand what is important in the claim form - Claim applications are to be filled carefully to avoid common mistakes. Even simple spelling mistakes / wrong dates / wrong policy number mentioned can lead to rejection. All documentation should contain clear information regarding the medical procedure done / scheduled, details of the insured, details of hospital / doctor etc.

Check for key information and possible mistakes - The claim form should be fully and properly filled. Make sure that the form has all correct information like Name of the Insured and policy holder, Address, Policy Number, Nature of illness / disease / Injury, Details of Hospital / Nursing home, details of the attending doctor, details of hospitalization..

3. Have you submitted all the supporting documents?

Check your checklist for discrepancies in the supporting documents - If your claim is rejected on account of insufficient / incorrect documentation kindly go through the following checklist and ensure that you comply:

- All original investigation reports, test reports
- All Prescriptions & Receipts
- Admission Form
- Discharge Summary
- Details of diagnostic tests
- Medical card details of the patient / policy holder
- Age proof
- Identity Proof
- Claim Form
- Any other document as required by your policy / Insurance Company

Make sure you submit all relevant documents and photocopies of important documents. Arrange the documents in chronological order. Remember to file the claim within prescribed time.

Find a way to submit the pending documents - If you have missed to submit any required document, contact your agent to find out the procedure to submit pending document.

4. Things to do if your ailment deemed is considered medically unnecessary:

Sometimes insurance companies claim that the tests / procedures performed are medically unnecessary. Again, key here is to understand your policy thoroughly as to what is covered and what is not covered. Do not claim costs which are not covered in the policy.
Gather medical proof - Gather sufficient medical proof to prove that the ailment is covered, there is no wrong classification and medical practitioner's opinion and investigations that prove that the treatment administered was medically necessary.

5. Steps to file an appeal:

Even after taking care of all above mentioned points, still you find difficulties in getting your claim which you feel is valid, you can file an appeal alongwith all necessary documentation and medical reports. To file an appeal you need a rejection / denial letter, policy document, your doctor's opinion in to support your claim, any other document as deemed necessary by the insurance company.

What to do if the response from insurance company is not satisfactory?

Even after filing an appeal you do not get any satisfactory response, you can file a written complaint with Health Insurance Ombudsman within 30 days from the response by the Insurer alongwith all necessary documents.
How can one avoid the situation of claim rejection?

To avoid landing in situations of claim rejection / follow-ups / appeal / complaint, follow the steps given below.
Understand your policy - Compare different policies before zeroing on one, go through and be clear about all terms & conditions

Coverage of the policy - Understand what all ailments & procedures are covered in your policy, which all hospitals & regions are in the network, with which doctors Insurance Company has tie-ups

Documentation - All prescriptions and payment receipts for bills & consultation fees, investigation reports, properly filled claim forms

Declarations - All existing illness and diseases should be disclosed so as to avoid further complications

The common belief that "Insurance Company aims to reject all claims" is not true. We need to take care of some points and once you understand, you will not be baffled by a huge hospital bill in spite of taking an insurance policy.

Be clear about your policy, disclose all facts, claim rejection reasons, proper and adequate documentation, and steps to follow if your claim is rejected.

K. Ramalingam is the chief financial planner at holisticinvestment.in, a leading financial planning and wealth management company.