Reasons why your health insurance claim can be rejected

Last Updated on August 11, 2022 by user

Health insurance claims can be tricky and the situation only gets worse if your claim was rejected. Here’s the what and why of claim rejection!

Health insurance claims by definition is when you request a reimbursement or direct payment from your insurance provider for the medical services obtained. Broadly, there are two types of health insurance claims, reimbursement claims and direct payment.

Direct payment is when you don’t have to pay the bill yourself and the hospital or clinic takes care of the settlement with the insurance company directly. Most insurance policies offer direct settlement, however, it is usually applicable only within the selected network. Reimbursement claims are when you have to pay the bill yourself and then get it reimbursed from the insurance provider later. With this type of claim, you have to keep in mind certain factors such as pre-authorization, hospitals and clinics that are not covered in the network and more.

When purchasing an insurance policy, your broker or insurer will generally explain to you the claims process but it is common for many policyholders to overlook the fine print which inevitably leads to rejection of a health insurance claim. There are specific reasons why your health insurance claim was rejected. You don’t need to be an insurance expert to understand these. We have broken them down for you.

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Negligence of terms and conditions: If you skim through the terms and conditions before signing over the dotted line, you are not alone. But this practice can be the reason why your claim was rejected. Reading the terms and conditions of the policy carefully and in advance is crucial as this will be of assistance during the following year when you use your policy. If you find the jargons too difficult to understand, you can always approach your insurance broker of insurer for assistance. Make sure you read and make a note of the exclusions, coverage limit, network and other important factors.

  • Claim form not filled properly: A lot of people fill the claim form either incorrectly or leave it incomplete. While it is understandable to be stressed during period of illness, filing your claim form properly is one of the basic requirements for a successful claim process to flow. Make sure to provide all supporting documents like hospital bills and reports that may be necessary.
  • Ailment out of coverage: Another reason why your claim may have been rejected is because the ailment you are trying to claim for is not covered in your policy. At this stage, you would want to go through the terms and conditions mentioned in your policy and get in touch with your health insurance broker or insurer to rectify the mistakes. If the ailment is not covered under your policy, you will not be able to claim for the treatment.
  • Policy renewal: Renewing your policy on time plays a huge role in facilitating claims. If you have not renewed your policy but have to file a claim, the insurance provider will reject your claim request. Your insurance provider will send a reminder before policy renewal to ensure you renew your policy on time.

If you are in a situation where your claim has been rejected, the first step would be to find out why your claim was rejected. Once you know the reason, you can fix the problem and apply for the claim again. If you place your insurance through a broker, they will be able to assist you through the entire process. Make sure you keep all documents, hospital bills and reports safe until you have received the claim for the treatment. Of course, the best option is to stay within your network and minimize the number of claims you make during the year. Solutions such as the Bayzat Benefits Insurance module is useful to help you access, learn about and navigate your health insurance policy.