11 Tips to Avoid Claim Rejection | Health Insurance Claim Rejection | Ditto

Hey folks, it's me Shashank and I'm here to tell you all the reasons why your health insurance claims can get rejected. First up, incorrect information on claim form. It may seem pretty basic but mistakes happen. For example, if you got pre-authorization for a gallbladder surgery from your insurer but your discharge summary also mentions a mold removal procedure, your insurer can reject the claim since only the gallbladder surgery was approved. So pro tip, get someone to double check your form. Next, waiting period. You have 3 waiting periods, mandatory 30 days, 2-3 years PD waiting period and 1-2 years specific illness waiting period depending on your policy. So read the fine print to know your waiting time before you even get that treatment or surgery and assume your insurer will foot your bill because they won't. This one's a classic, missing documents. Say you submit a claim for a knee surgery but forget to attach the surgeon's prescription with the hospital's discharge summary. Without these essential documents, the insurer has no proof of the procedure leading to a claim denial. So whether it's your doctor's report, prescription or even your discharge summary, if you can't provide them, your claim's going nowhere fast. Honestly, make a checklist and don't lose anything. Anything. Your policy lapsed. Now, I know paying premiums isn't very exciting but trust me, you overlook paying your annual premium, your health policy lapses, a month later you're hospitalized for an emergency procedure and since your policy isn't active, the insurer denies your claim. So set a reminder, pay your premiums and keep that policy alive. You never know when you need it. Here's a big one, pre-existing conditions. Say when you're purchasing your policy, you fail to disclose that you've been diagnosed with diabetes. Later when you submit a claim for treatment related to diabetic complications, the insurer denies it due to non-disclosure of PED, that is pre-existing condition. Now, it's not about hiding things, it's about full disclosure. So when you're buying health insurance, honesty is the best policy. Unless you like paying hospital bills out of your own pocket. Next up, non-network hospitals. Picture this, you go in for a treatment only to find out that the hospital isn't a part of your insurer's network. In such a case, you aren't getting a cashless claim but can claim for a reimbursement. But then, you have the hassle of submitting all the documents to your insurer, which can delay the claim. If you want cashless claims, stick to hospitals in your insurer's network. Otherwise, it's pay now, claim later, unless an emergency situation of course. Now, this one stings. Your treatment isn't covered by your policy. Now I know what you're thinking, Shashank, I've got a health insurance, isn't everything covered? But no. Say you undergo cosmetic surgery that isn't medically necessary. Since your health insurance policy explicitly excludes cosmetic procedures, your claim for surgery is denied. Every policy has exclusions, whether it's cosmetic surgery, weight loss procedures or that acupuncture session your neighbor swears by. But read your policy brochure carefully, unless you like unpleasant surprises. Say your policy has a sum insured limit of 5 lakh rupees. After several treatments in the year, you hit that limit. And when you need hospitalization again, the insurer denies the new claim as your coverage has been fully exhausted. Yep, your insurance isn't going to keep on paying. There's a cap on how much they'll pay out. So, keep an eye on those limits, whether it's room rent, surgery costs or overall sum insured. It's all fun and games, until you realize your insurance isn't covering your entire hospital stay. Assume you opt for stem cell therapy, which is still considered experimental in your country. Since this treatment isn't recognized or covered under your policy, the insurer, you guessed it right, rejects the claim. Whether it's experimental treatments or the latest wellness trend, if it's not backed by your insurer, your claim will be tossed out. Now let's talk about non-medical expenses. Look, I get it, you're in the hospital and suddenly the minibar looks very tempting. Since these aren't covered under your policy, the insurer denies the non-medical expenses. So, our suggestion, stick to claiming for what's actually medical. Surgeries, medicines, tests. As much as I'd love to get my popcorn reimbursed, that's not how it works. Look, insurers will pay your bills only in three situations. You need a surgery, you get hospitalized, the insurer takes care of the bill. Two, you need a small procedure and you get treated by the doctor in the hospital, the insurer covers this under daycare. Three, you get some diagnostic tests, the doctor suggests a procedure or hospitalization. In such a case, your insurer foots your tests and medical bill. If you go in for a treatment which is not medically necessary or suggested by your doctor, well, your insurer might just say, no. If the doctor says rest, you rest. If they say surgery, you get that surgery. So there you go, the top reasons why your health insurance claim could get rejected. But hey, if you've got your paperwork in order, picked the right policy and read the fine print, you will be smooth sailing. And if not, well, you know where to find us. So there you have it folks. Stay tuned for more. Happy insurance hunting.