Why do health insurance claims get rejected? Expert weighs in

Understanding why health insurance claims get rejected can help policyholders avoid common pitfalls. In a post on X, Nikhil Jha, an insurance advisor, listed down the key reasons: 

1. Non-disclosure of pre-existing diseases and medical history

Failing to disclose pre-existing conditions like diabetes or hypertension when purchasing a policy can lead to claim rejection. Insurers have the right to deny claims and even cancel policies due to material non-disclosure. All premiums paid up to that point will be forfeited. Always provide complete and accurate medical history when applying for insurance.

2. Pre-existing disease waiting period
Most health insurance policies do not cover pre-existing diseases immediately. Insurers typically impose a waiting period of 3-4 years before covering such conditions. If a claim is filed within this period, it is likely to be rejected. To avoid this, purchase health insurance early to complete the waiting period sooner.

3. Waiting periods for specific treatments
Certain medical procedures, such as cataract surgery and knee replacement surgery have a waiting period of 2-4 years. If you claim before this period is over, the insurer can reject it.

4. Room rent limit and proportionate deductions
Every health insurance plan sets a room rent limit, which impacts the claim amount. If a policyholder chooses a room beyond the allowed limit, they may face proportionate deductions, reducing the total reimbursement.

How to avoid this issue?

Choose a policy without a room rent limit
Check your policy terms carefully
If needed, port to a better plan that offers full coverage

5. Incorrect or incomplete documentation
To claim pre- or post-hospitalization expenses, you must provide:

Invoices
Doctor’s prescription
Medical reports
Failure to submit these documents may result in claim rejection.

6. Hospitalisation for diagnostic or monitoring purposes
Health insurance does not cover hospitalisation solely for diagnostic or monitoring reasons. If a patient is admitted for observation without receiving active treatment, the insurer may refuse to pay.

7. Medical necessity of hospitalisation
Insurers only cover hospitalisation that is deemed medically necessary. If they determine that hospital admission was not required, the claim may be denied.

Final tip: Always read the fine print of your policy, ensure proper documentation, and disclose all medical history to avoid claim rejections.