Being diagnosed with any of the illnesses or getting admitted can be usual at some point, but the real shock comes when your health insurance provider denies your claim for the expenses incurred during hospitalisation. Despite the insurance policy assures you a considerable amount to pay in case of an emergency, you’ll have to bear the entire amount on own. If we consider the annual report made a couple of years back, IRDAI said 14,693 claims were rejected in a particular year, involving Rs 245 Crore. But this is half the picture. In the same year, insurance companies also settled 7.26 Lakh claims on individual health insurance plans, where total payout was Rs 5,958 Crore.
The point is that insurance companies are in the business of pay claims, where they also have to make the insurance takers follow some obligations. Failing which surely lead to claim rejection. Here are some of the reasons for rejection of your health insurance claim!
1. Insufficient Knowledge:
It’s often noticed that insurance buyers don’t bother to read the policy fine print carefully. One of the most important sections of policy is EXCLUSIONS, not adhering to, which may lead to claim rejection. Let’s say if your policy says the pre-existing illness is permanently excluded. In such case, by ignoring the terms, if you make a claim for health emergency arising due to a pre-existing condition, your claim will be rejected by default. It is a serious mistake where you don’t even know when you breach a written condition of the policy.
Tip: Read policy fine prints carefully before you sign on the dotted line.
2. Not Disclosing the Facts:
An insurance contract is truly based on faith. You believe on the insurer for getting the much-needed financial protection in case of an emergency, while the insurer expects the contract is made on true information provided by you. Therefore, non-disclosure or partial disclosure or wrong disclosure of facts such as age, number of dependents, income, occupation, major illnesses or that are pre-existing etc. can lead to claim repudiate.
Tip: Try stating everything carefully and make sure every information you provide is true.
3. Letting others to fill the Proposal Form:
As we already have mentioned, insurance deal should be made on true information. When you allow a third-party to fill the policy proposal form, chances of a mistake in declarations are higher. An agent may not be aware of your exact personal details or s/he may try to crack this deal to meet the monthly target. If the insurer verifies the information and finds anything represented inaccurately, it can provoke claim rejection.
Tip: Fill the form yourself and submit the genuine documents.
4. Claim for Superfluous Expenditures:
In the segment of general insurance, health and motor insurance industry witness higher claim rejection. One of the most important reasons can be the service availed that is not medically required. Let’s say the private hospitals to generate more money, might have to undergo a medical procedure on the patient who is covered by health insurance. The insured will also be relaxed thinking that the procedure will be covered. But when insurer finds it unnecessary, it can deny the claim request and the entire expense will be on the policyholder.
These situations may create havoc by leading to claim rejection. Even if you own the best health insurance, the obligations bind the insurer to pay only for the genuine claims. Thus, make sure your claim is genuine!
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