In times of health emergencies, having a medical insurance policy can be an immense relief. It allows you to forego the financial worries of hospitalization so that you can focus on the rest and recovery of the admitted patient. All one has to do is raise a claim with the insurance provider. Nowadays, with the cashless service available, the process is even easier. However, there might be times when your claim might be rejected for one reason or another. Not knowing what to do in this scenario can increase your stress levels at an already difficult time. That is why we have compiled the steps you can take if your insurance claim is rejected.
- Understand why the claim was rejected
There are various reasons why a claim may be rejected by the insurer, namely:
- The claim was filed for an event/illness excluded under the policy.
- The insurer came to know that important medical information regarding the insured was being withheld.
- The insurer felt that there was no need for hospitalization.
- There is not enough medical record/documentation to support the claim.
- The waiting period for the medical insurance policy is currently ongoing
Once you have understood the reasons for the rejection of the medical insurance claim, you can act accordingly. *
- Rectify the mistake, if there is any, on your part
If the claim has been rejected for a reason that you feel can be rectified by you, then you should try to rectify it. For instance, if the claim has been rejected because the insurer feels there was no need for hospitalization, then you can reach out to another licensed medical practitioner to help the insurer understand why the hospitalization had to take place. If the claim has been rejected because of insufficient bills, then you can try reaching out to the hospital/medical centre once again to ask for more evidence of hospitalization and the consequent expenses. *
- Consider applying to the grievance committee
If you have tried approaching your insurer after the rejection of your insurance claim with no positive result and feel that this issue needs further resolution, then you can try going to the grievance committee of the insurance company. You will have to provide the details of your policy, the claim number, relevant documents, opinions, and bills provided by the medical centres, and so on. The grievance committee will consider this evidence and resolve the situation accordingly.
The IRDAI has issued a turn-around time within which insurers are expected to resolve the grievance applications sent by policyholders. You can visit the official website of IRDAI for further details. *
- Approach the Ombudsman or the consumer court
If the resolution passed by the grievance committee is not satisfactory, then you can consider approaching an outside party such as the Ombudsman or the consumer court to solve the matter. While the first acts as a counsellor or a mediator to come to a mutually agreeable conclusion, the latter will resolve the issue in court style with the help of legal aid and the like. *
* Standard T&C Apply
Do reach out to an insurance expert or a financial consultant before proceeding with any major decisions regarding your family health insurance claim. Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.
