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How to Appeal Against Health Insurance Claim Denial?

Team AckoJun 7, 2024

Facing a major health issue is not only worrisome for you, but it is equally worrisome for your loved ones as well. While it is, in fact, scary, having health insurance by your side can help you out to a massive extent.

Emergencies do not come to your door knocking. Irrespective of who you are, health insurance is the key to tackling a health emergency. Thankfully, there are quite a few health insurances available. While applying for health insurance may be an easy task, getting rejected from one surely has a negative impact. If that has been the case for you recently, you are at the right place.

Contents

Know more about Claims and a Health Policy
Factors That Every Policyholder Must Know Before Going To Court
Wrapping Up
Frequently Asked Questions:

Know more about Claims and a Health Policy

What’s The Reason?

Insurance companies, have a strong reason for rejecting a health policy claim. More often than not, it is communicated while rejecting the claim application. If not, then a policyholder can request for the same. Once you know the reason, who can make amends (if possible) and reapply.

The first step performed by the claims team after receiving a claim application is to check for policy details of the applicant. Basic details such as names of people covered, policy validity, and inclusions are checked and verified. Here’s a list of major issues faced by the claims team that lead to claim rejection:

Claim is raised for an issue that is not covered under the policy

Claim is raised in case of an expired policy

Necessary details are missing in the claim application

Supporting documents (if any) are not provided

Claim is raised for someone who is out of the policy’s purview

Ways to appeal a health plan decision

You can certainly ask your health insurance company to reconsider the decision. It is a must that the insurers tell you why they have rejected your claim. Additionally, they have to let you know how you can appeal their decision.

External review

You have the right to take the appeal to an independent third party for review. It is acknowledged as an external review. It basically means that the insurance company no longer has the final say over if you need to pay a claim.

Internal appeal

If the claim is denied or the health insurance is cancelled, you do have the right to make an internal appeal. You can ask your insurance company to carry out a fair and complete review of the decision. If your case is urgent, the company should be fast with their processes.

Rectifying & Reapplying

Once you know the reason, you can rectify it (if possible) and reapply. However, if the reason for rejecting the claim was ‘claim raised for expired policy’ and other such instances, then there is no way the claim shall be accepted. Make sure to understand the reason for rejection and ways to rectify the same by getting in touch with your insurance company’s executive. The same can be done on call or email. It is better to have a written trail mail in case of such communication.

Also, check: Cashless Health Insurance

Approaching the Ombudsman

Government of India, created the Insurance Ombudsman to help policyholders to settle complaints. You can write to the Ombudsman of your location to raise a complaint against your insurer. The complaint can be about delay in claim settlement, premium dispute, misrepresentation of terms and conditions, and other issues with respect to Insurance Act, 1938.

The Ombudsman approach is an impartial and an out of court system. The Ombudsman acts as a mediator between the policyholder and the insurer in case of a complaint and arrives at a fair recommendation based on the facts available.

Proactive Approach

Instead of suffering in case of a wrongly purchased policy or a wrongly filed claim, it works best if you read and understand the terms and conditions of a policy before purchasing it and raising a claim for it. The proactive approach to purchasing a health insurance policy is to analyze your requirements and buy a policy that covers these requirements. The inclusions and exclusions of the policy are clearly mentioned in the policy document.

Online Health Insurance Plans

Earlier, the only way to purchase health insurance plans was the offline method. It involved visiting the insurer’s branch office or relying on an agent for the policy. Here, there was scope for personal agendas to be forwarded by the person offering the policy. Also, there were chances of misrepresenting personal details as they were the one’s filing lengthy application forms.

Today, such issues can be discarded thanks to online health insurance plans. You can easily read and understand the policy’s inclusions and exclusions on your own as the information is conveyed in a simple and transparent manner in the online method. Chances of misrepresentation are also less as you have to provide information yourself.

Make an informed choice and stay insured.

Factors That Every Policyholder Must Know Before Going To Court

Valid and Active Policy Requirement:

Firstly, the policyholder must check that all policy premium dues are clear. Then, they must submit all documentation and details relevant to their past and present medical condition to the insurer. This is a crucial step to follow when availing of the policy.

Your policy must be valid when making an insurance claim. Also, check if the policy covers the medical condition for which you’re making a claim. Lastly, policyholders must double-check if they have submitted authentic medical records and admission/discharge statements to the insurer.

No matter the scenario, the insurer seeks documentation both ‘before’ and ‘after’ lodging the insurance claim. The policyholder must claim insurance for the ailment that their policy cover. If it does cover, they need to share and lodge all supporting documents with the insurer.

Policyholder Must Make Full Disclosure In The Policy:

It is good faith that holds the contract between an insurer and a policyholder. Given that, it is the primary obligation of the policyholder to provide correct and authentic details regarding everything to the insurer during the policy issuance period.

Wrapping Up

Irrespective of the reason for rejecting your health insurance, you must ensure you diligently follow up with the insurance company. Additionally, it is a must that you ensure proper documentation and adherence to the insurance company to steer clear of any kind of denial scenarios in medical billing.

Frequently Asked Questions:

Here are some Frequently Asked Questions related to Health Insurance Claim Denial

When can health insurance be denied?

Insurance companies may reject a health insurance claim for a variety of reasons, including incomplete or inaccurate information and improper documentation.

How will you resolve a rejection denial from the insurance company?

You have the option to file an appeal if you think the insurance company made a mistake in its decision. This can entail sending the insurance company a formal request outlining your case for approving the claim. Additionally, you might be allowed to make your case in front of a review board.

What is the difference between rejection and denial?

Insurance claims are typically denied prior to the policy being completed due to incomplete or inaccurate information. On the other hand, after the request is processed, it can be denied. Insurance coverage conditions, expired policies, and other reasons may be the basis for an insurance denial.

If a woman policyholder dies during childbirth, is her insurance claim denied?

If the claim fits the inclusions of the insurance policy then it can be approved. However, the insurance company may do a thorough review before making payment.

Are there cases where insurance claims cannot be appealed for?

Yes. A denial of an insurance claim cannot be challenged in situations when the cause of death was from an exclusion of the policy.

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Disclaimer: *Except for exclusions like maternity benefits, undisclosed diseases, etc. Please check policy wordings for more details.

**The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet; and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content and before making any insurance-related decisions.