When you first got a call from your Agent selling you a health insurance policy, you weren’t interested but he made such convincing arguments that you wanted to buy it just at that moment. Somehow the agent made you feel that health insurance covers all hospitalization costs and the claim procedure is a simple one.
And now that this is your first claim in years, you expect your claim to be settled fast. But soon you realize that you were mistaken about the simplicity of the claims procedure when the company rejected your claim.
If you are stumped and thinking what to do next while cursing the health insurance company and are about to give up, Don’t! We give you reasons as to why your claim might be rejected and what you can do to get it approved.
Know the reason for Claim rejection:
- Ailment not being covered in the health insurance policy
- Improper claim form filled
- Procedure deemed medically unnecessary
- Claim not filed in time
What you can do now:
Know the reason: The TPA, a representative of the health insurance company will have given you a reason why your claim is being rejected. Understand it fully or if you cannot understand the terms, call your Agent or Broker and ask him or her to guide you through it. If you are covered under group health insurance policy, you can contact your broking firm and it will handle the further claim process.
Once you know the reason why your claim rejected, unless the ailment is not covered or you have not filed the claim in time, you can still convince the insurance company that the claim is valid.
Check Medical Insurance Claim form:
See the medical insurance Claim form that you sent to the insurance company to check whether all the information is accurate- the important two things to check are- name and policy number. If there is any mistake in filling of the medical insurance claim form, you should resend the correctly filled medical insurance claim form and call the TPA and inform them about the error and ask them to reopen your case.
Contact the TPA:
Sometimes many claims are rejected due to systemic errors or due to incomplete data provided, and by actually talking to the representative you can solve the matter there itself. Remember to keep all the mails or phone conversations with the health insurance representatives documented for further reference.
Check Medical Insurance Documents submitted:
Along with the medical insurance claim form, check the other documents provided for accuracy and correct data. If the documents sent are incomplete or insufficient, gather all the important documents that you will need i.e. all medical reports, letter of recommendation for hospitalization, consultation fees, final bills, lab reports, medicine bills, discharge summary, receipts etc.
Gather medical proof:
If the claim is rejected on the basis that the treatment was medically unnecessary, you need gather medical opinion and medical research that will prove that the treatment was necessary and valid if the ailment is covered.
File an appeal:
Once you are ready with all the necessary data and documents, you can begin the appeals process. You have to write a formal letter stating the reason why you think your claim is a valid one. You must attach all the necessary documents as well medical opinion of the doctor in writing to substantiate the claim.
There are multiple appeals available, hence, even if the first appeal is rejected, you can still appeal again.
In case response by the health insurance company seems inadequate or unsatisfactorily or if the health insurance company does not respond to you in 30 days, you can approach the Health insurance Ombudsman. Here you need to lodge a written complaint with the Office of insurance Ombudsman within 30 days of the response of the health insurance company.
Here is how you can avoid each of these:
- Read the policy wordings very carefully at the beginning so that you are aware of what is covered and what is not.
- Take copies of all the documents that you submit along with the medical insurance claim form to the TPA for future reference.
- Submit the claim request within 30 days of the hospitalization if you are including the post hospitalization expenses; send it within 90 days of hospitalization.
- Check all the details provided in the medical insurance claim form for accuracy.
- Send all the necessary medical records to the TPA.
- Gather sufficient medical opinion in support of the treatment and send it to the TPA.
Now that you know how to get your claim settled, hurry, start the process now and remember to use the tips to avoid making the same mistakes again.