How to Appeal Against Health Insurance Claim Denial?

Team AckoFeb 2, 2023

Facing a health issue can be a daunting task not only for the patient but also for the family members. In such a scenario, the cushioning of a health insurance policy emerges as a support system. However, if the health insurance policy claim is rejected, it can lead to severe trauma. Yes, health insurance companies do reject claim applications. But you have the option to appeal against a rejected claim.

How to Appeal Against Health Insurance Claim Denial?

Contents

Know more about Claims and a Health Policy

Know more about Claims and a Health Policy

What’s The Reason?

Insurance companies, have a strong reason for rejecting a health policy claim. More often than not, it is communicated while rejecting the claim application. If not, then a policyholder can request for the same. Once you know the reason, who can make amends (if possible) and reapply.

The first step performed by the claims team after receiving a claim application is to check for policy details of the applicant. Basic details such as names of people covered, policy validity, and inclusions are checked and verified. Here’s a list of major issues faced by the claims team that lead to claim rejection:

Claim is raised for an issue that is not covered under the policy
Claim is raised in case of an expired policy
Necessary details are missing in the claim application
Supporting documents (if any) are not provided
Claim is raised for someone who is out of the policy’s purview

Rectifying & Reapplying

Once you know the reason, you can rectify it (if possible) and reapply. However, if the reason for rejecting the claim was ‘claim raised for expired policy’ and other such instances, then there is no way the claim shall be accepted. Make sure to understand the reason for rejection and ways to rectify the same by getting in touch with your insurance company’s executive. The same can be done on call or email. It is better to have a written trail mail in case of such communication.

Also, check: Cashless Health Insurance

Approaching the Ombudsman

Government of India, created the Insurance Ombudsman to help policyholders to settle complaints. You can write to the Ombudsman of your location to raise a complaint against your insurer. The complaint can be about delay in claim settlement, premium dispute, misrepresentation of terms and conditions, and other issues with respect to Insurance Act, 1938.

The Ombudsman approach is an impartial and an out of court system. The Ombudsman acts as a mediator between the policyholder and the insurer in case of a complaint and arrives at a fair recommendation based on the facts available.

Proactive Approach

Instead of suffering in case of a wrongly purchased policy or a wrongly filed claim, it works best if you read and understand the terms and conditions of a policy before purchasing it and raising a claim for it. The proactive approach to purchasing a health insurance policy is to analyze your requirements and buy a policy that covers these requirements. The inclusions and exclusions of the policy are clearly mentioned in the policy document.

Online Health Insurance Plans

Earlier, the only way to purchase health insurance plans was the offline method. It involved visiting the insurer’s branch office or relying on an agent for the policy. Here, there was scope for personal agendas to be forwarded by the person offering the policy. Also, there were chances of misrepresenting personal details as they were the one’s filing lengthy application forms.

Today, such issues can be discarded thanks to online health insurance plans. You can easily read and understand the policy’s inclusions and exclusions on your own as the information is conveyed in a simple and transparent manner in the online method. Chances of misrepresentation are also less as you have to provide information yourself.

Make an informed choice and stay insured.

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Disclaimer: *Except for exclusions like maternity benefits, undisclosed diseases, etc. Please check policy wordings for more details.

**The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet; and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content and before making any insurance-related decisions.