Why Health Insurance Claim May Be Rejected If…

SOURCE : NEW18 NEWS

Last Updated:May 08, 2025, 17:09 IST

Learn why health insurance claims get rejected—from wrong info to policy lapses—and how to avoid costly mistakes when you need coverage the most

Health insurance is designed to offer financial protection during medical emergencies, particularly for cashless or regular hospitalisations. Yet, despite paying premiums, some policyholders find themselves in a frustrating and stressful situation: claim rejection.

When faced with an already difficult circumstance, such as the hospitalisation of a loved one, a denied claim can only make matters worse. To help policyholders avoid such pitfalls, it’s essential to understand the most common reasons health insurance claims are rejected and how these rejections can be prevented.

Why Health Insurance Claims Get Rejected?

1. Incorrect or Incomplete Information: Submitting inaccurate personal details on the insurance application, such as age, income, occupation, or lifestyle habits, can result in claim rejection. Even small errors can lead to complications.
2. Non-Disclosure of Medical Conditions: Failing to disclose pre-existing medical conditions or lifestyle choices like smoking and alcohol use is a major reason for denial. Transparency is critical at the time of policy purchase.
3. Waiting Periods: Every health insurance policy includes a waiting period, typically 30 days from the policy start date. Claims made during this time are generally not accepted. For certain conditions, such as maternity (24–36 months) or pre-existing diseases (2–4 years), the waiting periods are longer.
4. Treatment Outside Network Hospitals: Cashless treatment is only available at hospitals within the insurer’s network. If treatment is taken at a non-network facility, the cashless claim may be declined, although reimbursement may still be possible.
5. Excluded Treatments: Some procedures, such as dental work, AYUSH therapies, outpatient consultations (OPD), or maternity services, may not be included in all policies. Filing claims for non-covered treatments can result in rejection.
6. Policy Lapse: If a policy is not renewed within its validity period (1, 2, or 5 years), it lapses. Any claims made during a lapse period will be rejected, regardless of merit.
7. Claim Amount Exceeds Sum Assured: Claims that exceed the policy’s insured limit are typically rejected. Always be aware of your sum insured and choose top-ups if needed.
8. Delayed Hospital Notification: For cashless claims, it’s vital to inform the insurance company within the stipulated time, usually 24 to 48 hours of admission. Failing to do so can lead to claim rejection.

How To Avoid Health Insurance Claim Rejections

1. Fill out your policy form personally to ensure all details are accurate and up to date.
2. Disclose all health conditions and lifestyle habits honestly; don’t hide any medical history.
3. Understand and observe the waiting period before making claims.
4. Renew your policy on time to avoid lapses.
5. Notify the insurer promptly after hospitalisation, within 24 to 48 hours, for planned or emergency admissions.
6. Check your hospital’s network status before opting for treatment to ensure cashless facility eligibility.
7. Review policy exclusions so you’re not caught off guard when making claims.

By staying informed and proactive, policyholders can significantly reduce the chances of claim rejection and ensure their health insurance works exactly when it’s needed the most.

First Published:

May 08, 2025, 17:09 IST