1. What to Do If Your Health Insurance Claim Gets Rejected?

So, you did everything right:

• Bought one of the best insurance,
• Disclosed all pre-existing conditions,
• Paid your premiums diligently.

But when the time came, your claim got rejected. Reason?

“Hospitalization was not required; patient could have been managed on OPD.”

𝘍𝘳𝘶𝘴𝘵𝘳𝘢𝘵𝘦𝘥, 𝘺𝘰𝘶 𝘳𝘦𝘢𝘤𝘩 𝘰𝘶𝘵 𝘵𝘰 𝘵𝘩𝘦 𝘪𝘯𝘴𝘶𝘳𝘢𝘯𝘤𝘦 𝘤𝘰𝘮𝘱𝘢𝘯𝘺. 𝘉𝘶𝘵 𝘸𝘩𝘪𝘭𝘦 𝘵𝘩𝘦𝘳𝘦 𝘢𝘳𝘦 𝘮𝘶𝘭𝘵𝘪𝘱𝘭𝘦 𝘯𝘶𝘮𝘣𝘦𝘳𝘴 𝘵𝘰 𝘣𝘶𝘺 𝘢 𝘱𝘰𝘭𝘪𝘤𝘺, 𝘵𝘩𝘦𝘳𝘦’𝘴 𝘯𝘰𝘵 𝘢 𝘴𝘪𝘯𝘨𝘭𝘦 𝘥𝘪𝘳𝘦𝘤𝘵 𝘭𝘪𝘯𝘦 𝘧𝘰𝘳 𝘤𝘭𝘢𝘪𝘮 𝘴𝘶𝘱𝘱𝘰𝘳𝘵. 𝘐𝘯𝘴𝘵𝘦𝘢𝘥, 𝘺𝘰𝘶’𝘳𝘦 𝘨𝘳𝘦𝘦𝘵𝘦𝘥 𝘣𝘺 𝘢 𝘴𝘵𝘢𝘵𝘦-𝘰𝘧-𝘵𝘩𝘦-𝘢𝘳𝘵 𝘈𝘐 𝘤𝘩𝘢𝘵𝘣𝘰𝘵.

𝘈𝘧𝘵𝘦𝘳 𝘨𝘦𝘵𝘵𝘪𝘯𝘨 𝘱𝘢𝘴𝘵 𝘵𝘩𝘦 𝘤𝘩𝘢𝘵𝘣𝘰𝘵, 𝘺𝘰𝘶 𝘧𝘪𝘯𝘢𝘭𝘭𝘺 𝘳𝘦𝘢𝘤𝘩 𝘢 𝘳𝘦𝘢𝘭 𝘩𝘶𝘮𝘢𝘯, 𝘰𝘯𝘭𝘺 𝘵𝘰 𝘳𝘦𝘢𝘭𝘪𝘻𝘦 𝘵𝘩𝘦𝘺’𝘳𝘦 𝘯𝘰𝘵 𝘧𝘳𝘰𝘮 𝘵𝘩𝘦 𝘤𝘭𝘢𝘪𝘮𝘴 𝘵𝘦𝘢𝘮 𝘢𝘯𝘥 𝘤𝘢𝘯’𝘵 𝘩𝘦𝘭𝘱 𝘸𝘪𝘵𝘩 𝘢𝘯𝘺 𝘳𝘦𝘤𝘰𝘯𝘴𝘪𝘥𝘦𝘳𝘢𝘵𝘪𝘰𝘯. 𝘐𝘯𝘴𝘵𝘦𝘢𝘥, 𝘵𝘩𝘦𝘺 𝘴𝘪𝘮𝘱𝘭𝘺 𝘳𝘦𝘱𝘦𝘢𝘵 𝘵𝘩𝘦 𝘳𝘦𝘫𝘦𝘤𝘵𝘪𝘰𝘯 𝘳𝘦𝘢𝘴𝘰𝘯, 𝘰𝘳 𝘢𝘵 𝘣𝘦𝘴𝘵 𝘵𝘳𝘺 𝘵𝘰 𝘱𝘳𝘰𝘷𝘪𝘥𝘦 𝘢 𝘫𝘶𝘴𝘵𝘪𝘧𝘪𝘤𝘢𝘵𝘪𝘰𝘯.

At last, you give up. Everyone was right, insurance is a scam.

Except… it doesn’t have to end there. There’s a way to keep the fight alive, and here’s how:

𝐒𝐭𝐞𝐩 1: 𝐅𝐢𝐥𝐞 𝐟𝐨𝐫 𝐚 𝐫𝐞𝐢𝐦𝐛𝐮𝐫𝐬𝐞𝐦𝐞𝐧𝐭 𝐜𝐥𝐚𝐢𝐦

A cashless claim rejection is NOT a claim rejection, it is the rejection of the cashless facility, you can still file a reimbursement claim by submitting all necessary documents.

If this gets rejected, move to Step 2.

𝐒𝐭𝐞𝐩 2: 𝐄𝐬𝐜𝐚𝐥𝐚𝐭𝐞 𝐭𝐨 𝐭𝐡𝐞 𝐆𝐫𝐢𝐞𝐯𝐚𝐧𝐜𝐞 𝐑𝐞𝐝𝐫𝐞𝐬𝐬𝐚𝐥 𝐎𝐟𝐟𝐢𝐜𝐞𝐫 (𝐆𝐑𝐎)

Every insurer has a Grievance Redressal Officer (GRO), which is the highest escalation level within the company. You can write an email to the GRO of your insurance company explaining your case in-depth and requesting a reconsideration.

👉 https://lnkd.in/dmArYA_t

While waiting for their response, initiate Step 3.

𝐒𝐭𝐞𝐩 3: 𝐅𝐢𝐥𝐞 𝐚 𝐜𝐨𝐦𝐩𝐥𝐚𝐢𝐧𝐭 𝐰𝐢𝐭𝐡 𝐈𝐑𝐃𝐀𝐈

IRDAI provides the Bima Bharosa platform to all the customers to escalate claim issues where we can raise a complaint for further escalation and the insurer has to review the case once again.

👉 https://lnkd.in/ddg9WknY

If you don’t receive a concrete resolution even after that, proceed to Step 4.

𝐒𝐭𝐞𝐩 4: 𝐀𝐩𝐩𝐫𝐨𝐚𝐜𝐡 𝐭𝐡𝐞 𝐈𝐧𝐬𝐮𝐫𝐚𝐧𝐜𝐞 𝐎𝐦𝐛𝐮𝐝𝐬𝐦𝐚𝐧

This is the final escalation step, filing a complaint with the Insurance Ombudsman, who acts as an independent mediator to resolve disputes, however, depending on the location the entire process could take 2 to 6 months.

👉 https://www.cioins.co.in/

2. A simple rule of thumb In case of any ambiguity about whether a particular condition should be disclosed, ask yourself:

“𝘐𝘧 𝘐 𝘸𝘦𝘳𝘦 𝘶𝘯𝘥𝘦𝘳𝘨𝘰𝘪𝘯𝘨 𝘢 𝘴𝘶𝘳𝘨𝘦𝘳𝘺, 𝘸𝘰𝘶𝘭𝘥 𝘐 𝘵𝘦𝘭𝘭 𝘮𝘺 𝘥𝘰𝘤𝘵𝘰𝘳 𝘢𝘣𝘰𝘶𝘵 𝘵𝘩𝘪𝘴 𝘤𝘰𝘯𝘥𝘪𝘵𝘪𝘰𝘯?”

If the answer is yes, it’s material enough to be disclosed to the insurer too.

𝐏𝐫𝐨 𝐓𝐢𝐩:
When buying health insurance online, always click on “Yes” when asked about pre-existing conditions, even if it doesn’t apply, as this usually gives us a drop-down questionnaire, letting us review all listed conditions before selecting “No.”

3. “𝐍𝐨𝐧-𝐝𝐢𝐬𝐜𝐥𝐨𝐬𝐮𝐫𝐞 𝐨𝐟 𝐦𝐚𝐭𝐞𝐫𝐢𝐚𝐥 𝐟𝐚𝐜𝐭𝐬.”

𝐖𝐡𝐲? 𝐁𝐞𝐜𝐚𝐮𝐬𝐞 𝐢𝐭’𝐬 𝐚𝐯𝐨𝐢𝐝𝐚𝐛𝐥𝐞—and in many cases, the non-disclosed condition wouldn’t have even impacted the issuance of the policy. In fact, some plans might have even reduced or waived off the waiting periods had the condition been disclosed.

So, why does this keep happening?
Here are the top 3 reasons:

A. 𝐅𝐚𝐦𝐢𝐥𝐲 𝐦𝐞𝐦𝐛𝐞𝐫𝐬 𝐟𝐢𝐥𝐥𝐢𝐧𝐠 𝐨𝐮𝐭 𝐚𝐩𝐩𝐥𝐢𝐜𝐚𝐭𝐢𝐨𝐧𝐬 𝐨𝐧 𝐛𝐞𝐡𝐚𝐥𝐟 𝐨𝐟 𝐨𝐭𝐡𝐞𝐫𝐬 –

It’s common for children or relatives to purchase plans for their parents, but they may not always have complete knowledge of their medical history. This can lead to unintentional omissions that might impact future claims.

B. 𝐃𝐨𝐰𝐧𝐩𝐥𝐚𝐲𝐢𝐧𝐠 𝐚 𝐜𝐨𝐧𝐝𝐢𝐭𝐢𝐨𝐧’𝐬 𝐢𝐦𝐩𝐨𝐫𝐭𝐚𝐧𝐜𝐞 –

misconception that a common or “non-serious” condition or something which happened a long time back doesn’t count.

It’s easy to think something is minor, but it’s always better to disclose everything.

I remember a case where a gentleman purchased a plan for his parents and unknowingly missed disclosing a condition his father had even before he was born, one for which he was only occasionally taking an ayurvedic medication.

C. “𝐓𝐡𝐞 𝐢𝐧𝐬𝐮𝐫𝐚𝐧𝐜𝐞 𝐜𝐨𝐦𝐩𝐚𝐧𝐲 𝐝𝐢𝐝𝐧’𝐭 𝐚𝐬𝐤 𝐚𝐛𝐨𝐮𝐭 𝐭𝐡𝐢𝐬 𝐬𝐩𝐞𝐜𝐢𝐟𝐢𝐜 𝐜𝐨𝐧𝐝𝐢𝐭𝐢𝐨𝐧” –

This is a very common statement which we come across, but with thousands of recognized diseases, the application form can’t possibly list every single one of those. That’s why it’s always a good practice to proactively disclose any relevant medical conditions to ensure transparency.

4. 𝘞𝘩𝘦𝘳𝘦’𝘴 𝘵𝘩𝘦 𝘭𝘪𝘴𝘵 𝘰𝘧 𝘢𝘭𝘭 𝘵𝘩𝘦 𝘤𝘰𝘯𝘥𝘪𝘵𝘪𝘰𝘯𝘴 𝘮𝘺 𝘩𝘦𝘢𝘭𝘵𝘩 𝘪𝘯𝘴𝘶𝘳𝘢𝘯𝘤𝘦 𝘤𝘰𝘷𝘦𝘳𝘴?

– 𝘞𝘦𝘭𝘭… 𝘵𝘩𝘦𝘳𝘦 𝘪𝘴 𝘯𝘰 𝘴𝘶𝘤𝘩 𝘭𝘪𝘴𝘵. 𝘞𝘩𝘢𝘵?! 𝘛𝘩𝘦𝘯 𝘩𝘰𝘸 𝘥𝘰 𝘐 𝘬𝘯𝘰𝘸 𝘸𝘩𝘢𝘵’𝘴 𝘤𝘰𝘷𝘦𝘳𝘦𝘥?

– 𝘈𝘤𝘵𝘶𝘢𝘭𝘭𝘺, 𝘸𝘦 𝘥𝘰𝘯’𝘵, 𝘣𝘦𝘤𝘢𝘶𝘴𝘦 𝘩𝘦𝘢𝘭𝘵𝘩 𝘪𝘯𝘴𝘶𝘳𝘢𝘯𝘤𝘦 𝘸𝘰𝘳𝘬𝘴 𝘵𝘩𝘦 𝘰𝘵𝘩𝘦𝘳 𝘸𝘢𝘺 𝘢𝘳𝘰𝘶𝘯𝘥, 𝘸𝘦 𝘰𝘯𝘭𝘺 𝘬𝘯𝘰𝘸 𝘸𝘩𝘢𝘵’𝘴 𝘯𝘰𝘵 𝘤𝘰𝘷𝘦𝘳𝘦𝘥, 𝘢𝘯𝘥 𝘦𝘷𝘦𝘳𝘺𝘵𝘩𝘪𝘯𝘨 𝘦𝘭𝘴𝘦 𝘪𝘴 𝘢𝘴𝘴𝘶𝘮𝘦𝘥 𝘵𝘰 𝘣𝘦 𝘤𝘰𝘷𝘦𝘳𝘦𝘥.

This is a scenario we come across often, and, it is true that most insurers don’t provide an exhaustive list of covered ailments. Why?

Because there are thousands of medical conditions, each with multiple possible line of treatment based on factors like the doctor’s recommendations, hospital facilities, and the patient’s medical history.

Instead, insurers define exclusions—broad themes that outline what won’t be covered. Everything outside of these exclusions is generally considered covered.

Here are the top 3 exclusions that account for nearly 80% of claim rejections due to exclusions:

🚫 𝐃𝐞𝐧𝐭𝐚𝐥 𝐭𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭𝐬
Now, a lot of plans might mention that they cover dental treatments but what they are referring to are dental treatments done during a hospitalisation which is primarily in the case of accidents or cancer, however, most of us assume that they are referring to OPD treatments like filling, extractions, root canal, etc. which tend to be more common.

[Some plans do cover dental treatments on an out-patient basis up to a certain monetary limit, but they are either a bit more expensive or cut corners in the coverage of other ailments.]

🚫 𝐈𝐧𝐯𝐞𝐬𝐭𝐢𝐠𝐚𝐭𝐢𝐨𝐧 & 𝐄𝐯𝐚𝐥𝐮𝐚𝐭𝐢𝐨𝐧
Insurance doesn’t cover hospitalization for diagnostic purposes alone. Whether it’s a blood test, MRI, CT scan, X-ray, ultrasound, or any other diagnostic test, these are not covered unless they’re part of the treatment for a diagnosed condition.

🚫 𝐖𝐚𝐢𝐭𝐢𝐧𝐠 𝐩𝐞𝐫𝐢𝐨𝐝𝐬
Even though these are time bound exclusions and not permanent exclusion, these make up a big chunk of most claim rejections. Majorly there are 3 waiting periods which we get to see in almost every plan, namely:
i) Initial waiting period: For the first 30 days nothing but accidents will be covered.

ii) Specific Illnesses waiting period: A list of specific conditions is provided in the policy wordings by the insurer and these are not covered for the first 2 years (in most plans), for e.g. kidney stones, cataract, hernia, etc.

iii) Pre-existing diseases waiting period: Any hospitalisation due to or caused by a condition diagnosed prior to taking the plan will not be covered for 2-3 years.

Understanding these exclusions can help you avoid unexpected claim rejections and make informed healthcare decisions.

5.it’s better to take a base plan of 20 lakhs and a top-up for the rest:

Since high-cost surgeries can go up to 20 lakhs,

For cashless under two plans, approval wont give at a time, so to avoid any issues, it’s better to take a base plan of 20 lakhs and a top-up for the rest.

6. Full protection means you want to take for 3 Ds protection

Death (term) .. Disease (Health)….. Disability (P.A or accidental policy)