Way Out to Deal with Health Insurance Claim Rejections

It is frequently witnessed that policyholders get vexed when there is a rejection for a health insurance claim raised by them. It, sometimes, takes away their trust from a particular insurance partner or even from the concept of their health insurance. Foremostly, it is inapt to perceive a thought that insurance doesn't pay at the time of the dire situation because the insurers approve cashless or reimbursement claims, whichever is raised by the policyholder under the guidelines stated in the policy documents. The claim is rejected by the insurer only when the certified guidelines fail to meet the criteria. However, there is still a ray of hope left after the health insurance claim is rejected by the health insurance company.

Methods to troubleshoot the claim denial reasons

There is always some ratio of possibility in every rejected claim to get approved in the second attempt raised by the insured. However, it can be done when the insurance plan holder contains complete knowledge and understanding about the health insurance plan and the right method to re-apply for the claim.

There are instances when a claim is rejected on the basis of wrong or incomplete information fed by the claimant such as wrong policy number, missed some personal details, etc. Such errors are rectifiable which can lead to the approval of the claim. The insurance policyholder can approach Third Party Administrator to reopen the case and the insurance company should be explained the error made in the first attempt. In this scenario, the third-party administrator can play a vital role by suggesting a solution to correct the mistakes and finally document them formally to ensure no other hassle in the process.

Another common reason for the claim rejection is the missing of proper medical documents or bills that affect the credibility of the claim. To rectify this, the policyholder can re-submit all documents again i.e. already submitted and missed ones in the first claim attempt. If the documents proofs submitted in the second round of claim satisfy the insurer then it can smoothly lead the claim settlement.

At the times, the claim is denied when the disease is considered as a pre-existing medical disease and the insurer doesn't approve for its approval. In this situation, the policyholder can re-approach their previous medical bills to prove that it is not a pre-existing medical condition or even get the certificate from the certified doctor stating it is not an old disease developed in the patient's body. If the policyholder becomes successful in proving this then the insurance company may approve the claim.

Final Approach

However, even none of this troubleshooting of the claim denial reason works and the policyholder doesn't satisfy with the reason issued for the rejection of the claim, then there is a final and last resort left with the policyholder is to approach the Insurance Ombudsman. The Government of India has created an Ombudsman for the insurance sector to consider the grievances of the policyholders. They work independently to protect the interests of the policyholders.

A policyholder can approach them with a written application to raise a complaint against the insurance company. The Ombudsman works as a mediator and listens to the argument of both parties i.e. insurer and insured. Then they give a fair decision that has to be followed by both parties.

Conclusion

Nonetheless, it is mandatorily suggested to carefully read and understand the terms and conditions of the policy taken by the policyholder to avoid any such scenarios. With the advancement of technology, customers can easily consume the complete knowledge of the health insurance policy available on the website of the insurer or the web insurance aggregator that also serve customers with facilities such as complete details of the policy, free premium quotes, and comparison between different health insurance plans to help customers in making a right selection.

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