Everyone visits the doctor sooner or later and undergoes hospitalization for various reasons. To protect yourself against this medical emergency, you buy a health insurance. In exchange for your yearly premiums, you expect financial security in the event of a severe health issue.
In other words, health insurance or mediclaim is a contract between the health insurance company and the insured individual, wherein the health insurance company agrees to pay the insured individual hospitalization expenses to the extent of an agreed sum assured.
Health insurance covers not only hospitalization expenses but also day care expenses, pre hospitalization expenses like x-rays, blood tests, sonography etc for 30 days prior to hospitalization. Health insurance also cover post hospitalization expenses considered necessary by the physician up to 60 days after discharge from the hospital.
Most people are taken by surprise when their health insurance claim is denied. Health insurance claims management can be Denied for various reasons. To avoid this dreadful situation, let’s understand why your health insurance claim may be denied.
- Medical insurance claim can be rejected if the procedure, treatment or medication is specifically excluded from your health insurance policy.
- The health insurance provider can reject the claim if the insured individual has some pre existing disease which was not disclosed by the insured individual during the issuance of the policy. If the claim is made on that particular ailment, claim will definitely be rejected.
- The insurer may also deny claim if the documents provided by the insured individual are incomplete. For instance the Xray and Sonography test is not supported by the doctors certificate. This report will not be accepted the insurance company and the payment towards the same may be denied. Team Medimanage advices that all claims made to the insurance company should be well documented with certificates by the doctor.
- The mediclaim policy states that the insured individual should inform the insurance company of any hospitalization within 48 hours. If the claim is not notified within the given time frame as laid in the policy wordings, the insurance claim will be rejected.
- The health insurance company denies claims or returns pre authorization requests if the form is not properly filled. Clerical errors like incorrect address or diagnostic code can also lead to rejection of your claims.
- Health insurance claims denied if the tests conducted are experimental in nature to understand the cause of the illness.
Here’s how you can avoid this situation.
- Read the policy wording before buying the policy so that you are aware of what is covered and what is not.
- Check all the details provided in the insurance claim form for accuracy.
- Submit the insurance claim request within 7 days after discharge from the hospital, if you are including the post hospitalization expenses, the claim form should be submitted within 60 days of hospitalization.
- Keep copies of all the documents that you submit along with the claim form to the TPA for future references.
- Take assistance from your dedicated health broker, who is an expert in handling claim and can ease the complete process.
Now that you know how you can avoid claim denials, be relaxed as now you will be more confident in handling health insurance claims when it arises.
