How to Appeal Against Health Insurance Claim Denial?

Earlier, health insurance claim denial was a widespread problem- in India and globally. Trust me, when a health insurance claim is denied, it turns out to be a very stressful and frustrating experience. However, you need to understand that you have all the right to appeal against this decision. Before filing a complaint against your insurer, you need to know why they denied your claim.

n this article, we will discuss what are the key reasons for your health insurance claim rejection, how to appeal against a denied claim and many more.

Understanding the Reasons for Health Insurance Claim Denial

Review the denial letter carefully and take note of the specific reasons provided. This information will help you build a strong case for your appeal. Some common reasons for health insurance denied coverage are:

1. Wrong information

   Your claim will definitely get rejected if you have not submitted enough documents while filing a claim. However, you can ask for the claim again after submitting all the documents that are requested by your insurer.

2. Inadequate sum insured

   If you are going for multiple claims then you may not have an adequate sum insured to raise another claim request. This can result in a rejection of your claim.

3. Raising a claim against exclusion

   If you are raising the claim for the service which is not included, then your claim will get rejected. Check for the exclusions before making a claim. You can also call us to discuss the situation in detail and our in-house health insurance advisors are at your service 24X7.

4. Raising a claim during the waiting period

   Your claim will be automatically rejected if you raise it during the waiting period. Usually, 30 days is the initial waiting period for the health insurance policy. In case of critical illness or maternity requirements, the waiting period may vary on the policy.

5. Expired policy

   Your health insurance policy should be active. It will not provide the benefits if it is expired. In such case, either you need to renew your health insurance policy or you need to buy a new one.

6. Black-listed hospitals

   If you go for the treatment at the blacklisted hospital, then your claim will be rejected unless it is an emergency case.

   POV, check out the policy documents/wordings carefully when you are applying for a claim.

Ways to Appeal for Denied Health Insurance Claims?

As I said before, you can still appeal for the denied health insurance claims.

• We, at PolicyX.com track the record and review why these claims are rejected.
• Then we analyse the case with the customer and consult the concerned doctor.
• If the claim denial is not valid then you need to send a reconsideration letter to the insurance company, with the rectified documents and bills.
• After this, if your claim is rejected, you can approach the ombudsman, and click here for applying.

Things to Know Before Going to the Court

You need to make sure of a few things before going to the ombudsman court for claim rejection.

• Check whether you have paid all the premiums.
• You must have submitted all the documents and details related to the claim and past events.
• Your policy must be valid for the claim.
• Check if the health insurance policy covers the medical condition.
• You have disclosed all the important details about your health, including pre-existing conditions.

Bottom Line

Health insurance claim denial is an unwanted situation for anyone, especially when you are already dealing with a tough time in a medical situation. However, understanding the reasons for denial and taking the necessary steps to appeal can significantly improve your chances of success. By carefully reviewing your policy, gathering supporting documentation, and following the proper appeal procedures, you can increase your chances of receiving the coverage you deserve.

If you are also in this situation, then fight insurance denials. Get Help Now. Call us.

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