Here are the important steps you can follow to appeal a health insurance claim denial

Here are the important steps you can follow to appeal a health insurance claim denial  19th July 2022

If you are suffering from health issues and other illnesses, health insurance is crucial in covering the expenses for treatment and medicines. A safety net in the form of health insurance can take a significant load off yourself and your family. However, it can be nerve-wracking if your health insurance claim does not go through. An insurance claim can be rejected for various reasons, and depending on your insurance provider, they may or may not provide clear reasons why the claim was denied.

So, if you are worried about claim denials and want to know the next steps that need to be done, this article is for you.

What are the reasons for claim denial?
There can be many reasons why the insurance company may reject your claim. Upon receiving a claim, the insurance company cross-checks every document from the policyholder to verify the policy's validity and the claim's authenticity. Some of the significant reasons for claim denial are issues with the cover. There is a list of illnesses and treatments that insurance doesn't cover. If your claim falls under such a category, the insurance company can reject your claim. Other reasons could be missing information, expired validity, and lack of supporting documents.

How can you rectify and reapply?
If you are eligible to reapply, you should thoroughly go through every document and ensure that there is no missing information and that all the supporting documents are attached. After providing these documents, you can reapply for your insurance. However, if the reason for prior rejection was an expired policy, then you cannot reapply for the insurance. The validity period of your policy is the only contract holding the insurance company accountable to you. If a claim was made without an active policy, the insurance company is authosied to reject the claim.

How to write a letter of appeal to the insurance company?
This is probably one of the easiest and most effective ways to undo claim rejection. Write an appeal letter to the insurance company stating facts and attach supporting documents to strengthen your case. Papers such as treatment plans, medical bills, etc., are some examples of the supporting documents that you can use. If your claim looks valid to the insurance providers, they will approve them immediately.

Who is an ombudsman, and how can they help?
If none of the steps mentioned above works, you should consider going to an ombudsperson to review your claim. An ombudsman is an officer appointed by the government for the policy holders' fair disbursement of insurance money. Any grievance against an insurance company can be made to an insurance ombudsman. If your insurance claim was rejected or the company has not responded to your appeal, then the ombudsman is responsible for resolving the issue.
After careful consideration, the ombudsman recommends a settlement or an award that must be complied within the next fifteen to thirty days.

These are a few things you can do to ensure that your health insurance claim is approved. Health insurance claim rejection is not something that you need to stress about. Understanding why the plea was rejected and rectifying the issues will help you reapply for health insurance. Insurance companies must be careful against fraudulent claims, which is why they have stringent policies to disburse the insurance amount to the rightful people.

Before buying your health insurance in India, read all the papers carefully. Understanding the terms and conditions before purchasing your policy ensures that you have no trouble at the time of claiming the insurance. Analyse your requirements and opt for a tailor-made policy for you to reap the benefits of health insurance.

Click HERE to know more about health insurance in India.

Disclaimer: The information provided above is for illustrative purposes only. To get more details, please refer to policy wordings and prospectus before purchasing a policy.