🔍 Why Was Your Claim Denied?

Understanding why a claim was denied is the first step toward resolving the issue. Here are the most common reasons:

1. Lack of Pre-Authorization

Certain treatments—like surgeries, specialized scans, or long-term hospitalizations—require pre-approval (also called pre-authorization) from the insurer. If you skip this step, even if the treatment was necessary, the claim may be denied.

2. Policy Exclusions

Health insurance plans have specific exclusions. For example:

• Cosmetic surgery

• Dental treatments (unless accidental)

• Alternative therapies (unless specified)

• Pre-existing conditions during the waiting period
  If your treatment falls into these exclusions, the claim may not be eligible.

3. Incomplete or Incorrect Documentation

Even one missing document—like a prescription, investigation report, or discharge summary—can lead to rejection. Mistakes in dates, names, or policy numbers can also create issues.

4. Waiting Period Not Completed

Many conditions, including maternity, hernia, cataracts, joint replacements, or pre-existing diseases, come with a 1–4 year waiting period. If you make a claim during this time, it’s likely to be rejected.

5. Treatment or Hospital Not Covered

• Some insurers only offer cashless claims in network hospitals. If you get treated at a non-network facility, you might have to pay out of pocket.

• Additionally, non-standard or experimental treatments may not be covered.

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🛠️ What Should You Do If Your Claim Is Denied?

Don’t panic. There are steps you can take to understand, appeal, and possibly overturn a claim rejection.

✅ Step 1: Understand the Rejection

Your insurer will send a rejection letter/email outlining the reason. Read this carefully. Common phrases to look out for:

• “Pre-authorization not obtained”

• “Treatment not covered under policy”

• “Insufficient documentation”

• “Waiting period not completed”

✅ Step 2: Call the Insurer

Call customer care and ask for a clear explanation. Keep a record of:

• The date and time of the call

• Name of the representative

• Call ID/reference number

• Summary of what was discussed

✅ Step 3: Re-check Your Documents

Review your submission with a checklist:

• Final hospital bill

• Break-up of charges

• Discharge summary

• Doctor’s prescription

• Diagnostic test results

• ID and KYC documents

• Pre-authorization (if required)

Submit any missing or corrected documents if allowed.

✅ Step 4: File a Written Appeal

If the insurer sticks with their decision, you can file a written appeal. Include:

• A copy of your claim form

• Medical reports

• The rejection letter

• A clear explanation of your case
  Send it via email or registered post to your insurer’s grievance redressal team.

✅ Step 5: Escalate to the Insurance Ombudsman or IRDAI

If your appeal is ignored or unfairly rejected:

• File a complaint with the Insurance Ombudsman (free of cost)

• Or escalate to IRDAI’s grievance redressal portal: https://www.irdai.gov.in

They will assess your case independently and ensure your rights are protected.

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🧠 How to Avoid Claim Denials in the Future

Being proactive is your best protection. Here’s how:

1. Read and Understand Your Policy

Don’t just rely on your agent. Read the document carefully—especially:

• Coverage details

• Exclusions

• Waiting periods

• Network hospital list

• Claim process guidelines

2. Choose Network Hospitals

Always opt for hospitals that are listed under your insurer’s cashless network. This simplifies and speeds up the claim process.

3. Get Pre-Authorization for Planned Treatments

Inform your insurer in advance for planned surgeries, admissions, or major diagnostics. This improves your chances of approval.

4. Keep Records

Always save:

• Doctor’s prescriptions

• Test reports

• Hospital bills and receipts

• Communication with the insurer

These documents are your strongest defense during a claim.

5. Inform the Insurer Promptly

For emergencies, inform your insurer within 24 hours of hospitalization. Late notification can delay or void a claim.

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📌 Real-Life Scenario

Rahul had a ₹5 lakh policy. His mother was hospitalized for gallbladder surgery. The surgery went well, but the claim was denied because he didn’t inform the insurer within the 24-hour window—and the hospital was not part of the cashless network.

This shows how even small procedural errors can result in huge out-of-pocket costs.

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📝 Conclusion

Health insurance claim rejections are frustrating—but you’re not powerless. Know your rights, understand your policy, and take timely action.

If your claim is denied:

• Don’t accept it blindly

• Ask questions

• File an appeal

• Escalate if necessary

Remember, you bought insurance to protect yourself—don’t let lack of information take that away from you.