TLDR Summary
- Read your policy terms, inclusions, exclusions and waiting periods before raising a claim.
- Disclose relevant medical conditions accurately while purchasing or renewing your policy.
- Keep hospital bills, discharge summaries, prescriptions, diagnostic reports and other claim documents safely.
- Provide accurate and consistent information across the claim form and supporting documents.
- Inform the insurer about planned or emergency hospitalisation as required under the policy.
- Check whether the treatment, hospital and expenses are covered under your policy.
- Respond promptly if the insurer asks for additional documents or clarification.
- If your claim is rejected, review the rejection communication and the specific policy condition cited.
- If you disagree with the decision, you can use the insurer's grievance redressal process and, where applicable, escalate the matter through the prescribed channels.
A health insurance policy can help manage the financial impact of hospitalisation and medical treatment. However, submitting a claim does not automatically mean that every expense will be payable. The insurer assesses the claim based on the policy terms and conditions, coverage, exclusions, waiting periods, documentation and other applicable requirements.
A health insurance claim rejection can happen when the claim does not meet the policy conditions or when required information is incomplete or inconsistent. Understanding common health insurance claim rejection reasons can help you submit your claim correctly and reduce avoidable delays or disputes.
1) Incorrect information or misrepresentation
While filling out the health insurance application form, you should ensure that all the information you are filling out is accurate. There should be no intentional or unintentional misrepresentation of any information; otherwise, it can lead to claim rejection. The information may be about your:
- Age,
- Income,
- Existing medical insurance policies,
- Profession (specifically if you are in a hazardous occupation),
- Hobbies (specifically if you are into adventure sports like hiking or scuba diving), etc.
All the above is material information for the health insurance company to decide whether they should accept the health insurance application and at what premium.
You should fill out the application form yourself rather than asking your agent or someone else to fill it out. They may not have all the required information about you to fill out the form accurately.
2) Information about pre-existing illnesses and bad habits
Non-disclosure of information about your own pre-existing illnesses, family history of illnesses, sedentary lifestyle, habits like smoking, alcohol drinking, etc., can lead to rejection of health insurance claims. Some people may conceal this information to avoid paying higher premium and policy rejection.
While filling out the health insurance application form, you must disclose the details of any pre-existing illnesses that you may be suffering from. If some disease runs in your family, you should mention it in the family history or medical history section.
If you smoke, the insurance company may ask about how many cigarettes you smoke daily. If you consume alcohol, you may be required to disclose the quantity of alcohol you consume and the frequency.
All the above information helps the health insurance company to price the risk appropriately. If required, the insurance company may include an exclusion or appropriate waiting period for coverage of a specific pre-existing illness.
3) Making a claim during the waiting period
Every health insurance plan may have certain waiting periods. If a claim is made during this waiting period, it will be rejected. Some of these waiting periods include:
a) 30-day waiting period
When a new policy is issued, there is a 30-day waiting period during which no claim can be made. The exception to this is any claim arising from an accident.
b) Maternity waiting period
If the policy provides maternity cover, it is usually applicable after a waiting period of 24 to 36 months. Also, the cover may be limited to 2 pregnancies.
c) Waiting period for specified diseases/procedures
The treatment for specified diseases/procedures can be claimed after a 24-month waiting period from the policy's inception. Some of these include cataract, varicose veins, piles, sinusitis, etc. The complete list of these diseases/procedures is specified in the insurance policy document.
d) Waiting period for pre-existing diseases
The claim for treatment for pre-existing diseases can be availed after a waiting period of 24 to 48 months from the date of commencement of coverage.
e) Critical illness waiting period
The claim for treatment of any critical illness may be covered after a waiting period of 90 days from the policy inception date.
Please read the policy wording for details of all the above waiting periods to understand how and when you can make a claim to avoid rejection.
4) Making a cashless claim at a non-network hospital
If a cashless claim is made at a hospital that is not a part of the insurance company's hospital network, it will be rejected. Hence, if you want to make a cashless claim, check with the hospital before admission if it is empanelled with the insurance company as a network hospital.
You will have to pay the hospitalisation bill from your pocket for treatment taken at a non-network hospital. Later, you can submit a reimbursement claim with the health insurance company.
5) Claims for services not covered
Certain services are not covered under every health insurance plan. They may be included in some policies with certain limits or other terms and conditions. If you make a claim for any of these services that are not covered, the health insurance company will reject the claim. Some of these services can include:
- Dental treatment
- AYUSH treatment
- Outpatient Department (OPD) services
- Maternity claim
If you want to make a claim for any of the above, read your policy document to check whether they are covered. If they are covered, check the extent to which they are covered and the related terms and conditions.
6) Exclusions
Certain treatments/procedures may be considered standard exclusions by all insurance companies. This means most plans will not cover them. Some of these may include:
- Cosmetic or plastic surgery
- Gender-change treatment
- Treatment due to participation in hazardous or adventure sports, such as rock climbing, motor racing, horse racing, scuba diving, gliding, etc.
- Treatment due to a person committing or attempting to commit a breach of law with criminal intent
- Treatment for alcoholism, drug abuse, or any other addictive condition
- Expenses related to sterility and fertility, etc.
The above are some of the exclusions included in most health insurance policies. For exclusions specific to your policy, check the policy wording (Exclusions Section)
7) A claim under a lapsed policy
A health insurance policy is valid for a specific duration, i.e., one year or multiple years for which the premium has been paid. Once the specified duration is over, the policy must be renewed by paying the renewal premium.
The policy will lapse if you don't pay the renewal premium within the specified time. If you make a claim under a lapsed policy, the insurance company will reject the claim. Hence, check the expiry date of your policy and pay the renewal premium on time to keep the policy active. It is recommended that you set up an auto-debit mandate for your policy to pay the renewal premium.
8) The claim amount is higher than the sum assured
Every health insurance policy has a specified sum insured. What if the claim amount is higher than the sum insured left (in case you have made claims earlier in the same year)? The insurance company will approve the claim up to the sum insured left, subject to policy terms and conditions.
With medical inflation increasing every year, you should review your health insurance cover amount every few years. Buy/upgrade to a higher cover amount to keep pace with medical inflation.
9) Not informing the insurance company on time
If you don’t inform the insurance company about hospitalisation within the stipulated time, the insurance company can reject your cashless treatment claim. If it is a planned hospitalisation, you may get the authorisation prior to hospital admission. If it is an emergency hospitalisation due to an accident or any other reason, inform the insurance company within 24 to 48 hours of hospitalisation, as per policy terms.
Steps to Appeal a Denied Health Insurance Claim
If your medical insurance claim is rejected, do not immediately assume that there is no further course of action. Start by reviewing the rejection communication carefully.
Under IRDAI guidance, when a claim is denied or repudiated, the insurer should communicate the reason and refer to the corresponding policy condition, along with information about available grievance redressal mechanisms.
Follow these steps:
- Read the rejection communication: Identify the exact reason given for the decision.
- Review your policy wording: Check the relevant coverage, exclusion, waiting period or other condition.
- Collect supporting documents: Gather medical records, bills, prescriptions, reports and other documents relevant to the issue.
- Clarify discrepancies: If incorrect or incomplete information caused the issue, provide the required clarification or documents.
- Submit a representation or grievance: Follow the insurer's prescribed process and retain acknowledgement of your communication.
- Escalate if required: If the matter remains unresolved, you can approach the appropriate grievance redressal mechanism.
Example Appeal Letters
You can structure an appeal or representation around the specific reason stated in the rejection communication.
Subject: Request for Reconsideration of Health Insurance Claim
Dear Sir/Madam,
I am writing to request a reconsideration of my health insurance claim bearing Claim No. [Claim Number], which was rejected citing [reason for rejection].
I have reviewed the policy terms and the documents submitted with my claim. I am enclosing the relevant supporting documents, including [list documents], for your review.
I request that you reconsider the claim based on the information and documents provided. Kindly review the case and communicate the outcome along with the applicable policy terms.
Regards,
[Policyholder Name]
[Policy Number]
[Contact Details]
Next Steps After Your Claim is Rejected
A rejection is not necessarily the end of the process. First, understand whether the decision relates to missing information, a policy exclusion, a waiting period, an exhausted limit or another condition.
If additional information can address the issue, submit the required documents or clarification through the appropriate channel. Keep copies of your claim form, medical records, correspondence and acknowledgement for your records.
If you disagree with the decision, you can raise a grievance with the insurer through its prescribed grievance redressal mechanism. If the grievance is not resolved within the applicable timeline or the response is unsatisfactory, you can approach IRDAI's Bima Bharosa mechanism and, where applicable, the Insurance Ombudsman. IRDAI states that insurers should resolve complaints within 15 days of receipt, while Bima Bharosa provides a mechanism to register and track complaints.
Immediate Steps to Take
When you receive a rejection, avoid delaying your response. Start with these steps:
- Note the claim number and date of the rejection.
- Read the stated reason carefully.
- Check the relevant section of your policy wording.
- Identify any missing documents or information.
- Gather supporting medical and billing records.
- Submit your clarification or representation through the appropriate channel.
- Keep acknowledgement and copies of all correspondence.
- Follow up within the applicable timelines.
ManipalCigna also provides online facilities to submit claim documents, upload shortfall documents and track cashless or reimbursement claim status.
Understanding Rejection Reasons
A health insurance claim rejection means the claim, as submitted, has not been accepted for payment based on the applicable assessment. The reason can vary from one claim to another.
Common reasons include waiting periods, pre-existing diseases, non-disclosure, policy exclusions, incomplete documentation, policy limits and other policy conditions.
Therefore, it is important to distinguish between a claim that is rejected because a treatment is not covered and one where the insurer needs additional information to assess the claim. Reading the rejection communication and the applicable policy wording can help you understand the next step.
Conclusion: Strategies to Ensure Health Insurance Claim Approval
A smooth claim experience starts well before a medical emergency. Understand your health insurance policy, disclose your medical history accurately, keep your policy active and maintain important medical and billing records.
When you need to raise a claim, follow the applicable intimation and documentation requirements and provide accurate information. ManipalCigna's claims process allows policyholders to submit documents and track claim status through its online claims facilities.
If your claim is rejected, review the reason carefully rather than assuming that no further action is possible. You can provide relevant clarification or documents and use the applicable grievance redressal process if you believe the decision needs to be reconsidered.
FAQs
What happens if insurance rejects a claim?
The insurer communicates the claim decision and the reason for rejection. Review the stated reason against your policy terms and supporting documents. If you believe the decision requires reconsideration, you can submit the relevant clarification, documents or representation through the prescribed process.
What can I do if my insurance claim is rejected?
Start by understanding the reason for rejection. Review the applicable policy conditions, gather supporting documents and submit a representation or grievance if appropriate. If the matter remains unresolved, you can use the applicable grievance redressal and escalation mechanisms.
Why do health insurance companies reject claims?
Claims may be rejected for reasons such as applicable waiting periods, pre-existing diseases, non-disclosure, policy exclusions, incomplete documentation, policy terms and conditions, misrepresentation, fraudulent claims, ailment sub-limits or an exhausted sum insured.
For what reason could a claim be refused?
A claim could be refused when the treatment or expense is not covered under the policy, a waiting period applies, the policy terms have not been met, required information is not provided, or there are issues such as non-disclosure or misrepresentation. The exact reason depends on the policy and the circumstances of the claim.
Can a claim be rejected after 3 years?
Yes, reaching three years does not by itself mean that every health insurance claim must be accepted. Under the current IRDAI framework, the moratorium period is 60 continuous months of coverage. After completion of this period, a health insurance policy and claim generally cannot be contested on the grounds of non-disclosure or misrepresentation, except in cases of established fraud, subject to the applicable regulatory provisions. Other policy conditions, exclusions, limits and coverage requirements continue to apply.
