- Definitions
- Know the Differences
- Avoid Rejected Claim
Claim Repudiated and Claim Rejected: The Concept
It is disappointing when you file a claim under your health insurance policy but it is rejected or repudiated. According to a survey done by Local Circles, many health insurance claims have been denied or partially approved in India in the last 3 years. On further research, it was found:
- 43% of individuals who filed a claim struggled with getting it processed
- Companies reject many health insurance claims by classifying a health condition as a pre-existing disease
- Health insurance companies only partially approve health insurance claims
An insurer’s claim settlement process is a hallmark of trust and reliability with the customers. This article extensively talks about claim repudiated and claim rejection, its reasons, and more. Stick around to find out how you can prevent your claims from rejection and repudiation.
Key Takeaways
- Claim rejection and repudiation can be due to many reasons like fraudulent document submission, withholding medical history, and more.
- Claim rejection and repudiation have a minute difference in consequences.
- Claim repudiation is the result of fraudulent or incorrect activities on behalf of the policyholder.
- Claim rejection is the result of incomplete documentation, or filing a claim for coverage not mentioned in your health plan.
What Is The Meaning Of Claim Repudiated?
Claim repudiation happens when the policyholder conducts some fraudulent activities while filing a claim. The fraudulent activities can vary from forged documents to missing out on medical condition disclosures, or more.
It is essential that you as a policyholder understand the terms and conditions of your health insurance plan to avoid future claim repudiation.
Why Are Health Claims Repudiated?
Some common reasons for claim repudiation are:
- The health insurance provider goes through your claim request and finds issues like incorrect documentation, fraudulent history, or incorrect data.
- If you file claims for any pre-existing ailments, specific treatments, or procedures that are not covered under the health plan your claims are repudiated.
- In case you do not fully disclose your medical history such as pre-existing ailments, past treatments, or procedures your health insurer may declare your claim as repudiated.
- On violating your health insurance terms and conditions your health insurer may apply a claim repudiation.
- Your claims can be repudiated if your claim request exceeds your policy sub-limits. This is why it is advised by policyholders to invest in health plans with adequate sum insured and unlimited sum insured restoration.
What Is The Meaning Of Claim Rejected?
Claim rejection is often the result when the policyholder files a claim for a procedure or treatment that is not covered by their health policy. Often when a claim filed is not within the terms and conditions of the coverage offered by the health insurance policy, it is rejected.
Why Are Health Claims Rejected?
Common reasons for claim rejection are mentioned below:
- Delayed claim filing is one of the most common reasons for claim rejection by the health insurer. Every health insurer has a specific time frame during which you can file a health claim which varies from insurer to insurer.
- Lack of proper documentation such as ID proof, hospital documents, prescriptions, policy numbers, and medical bills, may lead to claim rejection.
- If your health insurance claims fall over the coverage terms then your claims might be rejected. For example, filing a claim for pre-existing conditions or specific ailments which are not covered by your health insurer, your claim will be rejected.
- Raising a claim within the initial waiting period of 30 days is often rejected.
- Health insurance claims are rejected when you hide or withhold your medical history leading to further complications in your claim process.
Difference Between Claims Repudiated and Claims Rejected
Let us understand the difference between claim repudiated and rejections below:
| Claim Repudiated | Claim Rejected |
|---|---|
| Claim repudiation is the result of fraudulent activities by the policyholder like submitting false documents, withholding medical conditions, etc. | Rejected health claims are a result of the health insurance provider not deeming your claim request to be fit. The claim request can be reviewed and re-applied. |
| Reasons for repudiation include claiming after policy lapse, providing forged documents, policy violation, etc. | Reasons for rejection include claiming during the waiting period, hiding PED conditions, etc. |
What To Do If Your Health Claims Are Rejected or Repudiated?
If your claim is repudiated, do not worry. Follow these simple steps to file a proper claim request:
- Review and find out the reason for claim rejection or repudiation sent by your health insurance provider.
- Connect with your health insurance provider or experts at PolicyX.com to seek professional guidance regarding your claim repudiation.
- Re-read the policy terms and conditions
- In case you find mistakes or issues with your health claim documents, reach out to your health insurer with the correct documents.
- In case your health insurance claim is still not accepted reach out to an insurance ombudsman and seek legal advice.
Conclusion
Try and figure out the reason for your claim repudiation and rejection to have a smooth claim settlement process. The reason behind claim repudiation and claim rejection can be easily identified and rectified.
In case you are stuck in the process do not hesitate to seek professional advice from insurance experts at PolicyX.
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Claim Repudiated and Claim Rejected : FAQs
1. What is the difference between claim repudiation and claim rejection?
The difference between claim repudiation and claim rejection is very little depending on the consequences leading to rejection and repudiation. In case of claim repudiation, the policyholder conducts some fraudulent activities whereas rejection can be due to withholding vital health information from the insurer like PEDs, lifestyle habits (smoking/ consuming alcohol), etc. or due to exclusions of the health policy.
2. What does claim repudiation mean?
Claim repudiation means the rejection of a contract by breach of terms and conditions.
3. What is claim rejection?
A claim rejection is the result of wrong information provided by the policyholder or filing a claim for coverage that is not included in the health policy.
4. What are the most common reasons for claim rejection?
Claim rejection reasons may include filing a claim within the initial waiting period, incorrect submission of documents, filing a claim for pre-existing diseases which are not covered by your health insurance plan, etc.
5. What are the most common reasons for claim repudiation?
Common reasons for claim repudiation include, fraudulent documents, misinformation regarding medical history, forging documents, etc.
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Written By: Simran Kaur Vij
Simran is an insurance expert with more than 4 years of experience in the industry. An expert with previous experience in BFSI, Ed-tech, and insurance, she proactively helps her readers stay on par with all the latest Insurance industry developments.
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