Page 34 - The Insurance Times December 2024

Consumers

FAQs: Common Reasons for Health Insurance

Claim Rejections in India

H ealth insurance claims provide policyholders with tion of information lead to claim rejec-

crucial financial support during medical emer-
tion?
gencies, yet not all claims are approved. In In-
dia, health insurance claim rejections can occur
habits (like smoking), or pre-existing medical conditions dur-
for various reasons, often due to misunderstandings or over- Yes. Failure to disclose accurate health information, lifestyle
looked details in policy terms. Understanding the common ing application may be considered misrepresentation. Insur-
causes of rejection can help policyholders avoid pitfalls and ers can deny claims if they find that the policyholder with-
improve the likelihood of a successful claim. Here, we ad- held crucial information.
dress frequently asked questions about health insurance
Tip: Be transparent about your health history and lifestyle
claim rejections in India and ways to prevent them.
habits to prevent any issues when making a claim.
1. Why was my claim rejected due to a
4. How do policy exclusions impact claim
pre-existing condition?
rejections?
Insurance companies typically impose a waiting period for
pre-existing conditions. If a medical condition was diagnosed Policy exclusions are specific conditions or treatments that
are not covered under a health insurance policy. Common
before the policy's inception, it may not be covered until the
waiting period (usually 2-4 years) ends. A claim related to exclusions include cosmetic surgery, fertility treatments, and
this condition during the waiting period will likely be denied. alternative treatments (unless specified). Claims for any
procedures listed under exclusions will be denied.
Tip: Disclose all health information honestly during the ap-
Tip: Understand the exclusions in your policy to know what
plication process and check the waiting period clause for pre-
existing conditions in your policy. is covered and avoid filing claims for excluded treatments.

2. What does "waiting period" mean, 5. Why are claims rejected for unap-
and how can it affect my claim? proved treatments or hospitals?
Insurance companies often have a network of approved
The waiting period is the time a policyholder must wait
before claiming certain benefits. Most policies have wait- hospitals where cashless claims can be made. Claims from
ing periods for pre-existing conditions, specific treatments unapproved hospitals or for treatments that are not medi-
(like cataract surgery), and maternity benefits. If a claim is cally necessary may be denied, as insurers often verify the
filed during this period for a treatment that is subject to a necessity of procedures before approving claims.
waiting period, the insurer may reject it.
Tip: Choose hospitals within your insurer's network for cash-
less treatment and ensure treatments align with the
Tip: Always review the waiting period details in your policy
and avoid making claims for treatments falling within this insurer's definition of medical necessity.
period.
6. Can delay in filing a claim lead to re-

3. Can non-disclosure or misrepresenta- jection?

The Insurance Times December 2024 31