What to do if your health insurance claim is rejected?

What to do if your health insurance claim is rejected? How to handle and fight in case of such claim rejections? Let us learn from true story of a blog reader.

Insurance companies that are eager to sell will never show the same eagerness when it comes to claim settlement. This is the UNIVERSAL truth. Hence, buying health insurance is one aspect. However, if you don’t know how to fight back in case of claim rejection, then your health insurance may be useless. Over to you Sunil..

Living a healthy life free from major diseases and illnesses is a common goal for all of us. We strive to achieve this by maintaining awareness of our health, engaging in regular exercise, following a healthy diet, and seeking advice from medical professionals. Despite our best efforts, unforeseen circumstances may lead us to require hospitalization, which is why we invest in adequate health insurance to prepare for such situations. We hope that our insurance coverage will provide the necessary support when the need arises. However, the reality may not always align with our expectations.

We have experienced a situation that we believe can benefit others by sharing our story. Our aim is to help individuals become well-prepared, well-educated, and knowledgeable.

I have maintained a Family Floater Health Insurance policy with a well-known company for over 15 years. This company is listed on NSE/BSE and is recognized as the largest standalone health insurance provider with a significant presence in South India.

My wife was admitted to the hospital recently, and we opted to utilize her Employer insurance, which has limited benefits, for cashless settlement. The insurance covered 65% of the bill amount in accordance with its terms and conditions.

After being released from the hospital, I filed a claim with my private insurance for the remaining 35%, which meets the requirements of my insurance policy. I have submitted all the necessary documents, invoices, and reports for the claim to be processed.

I was shocked when my insurance company informed me that only 20% of the claimed amount was approved due to their incorrect accounting practices and erroneous calculations. I filed a complaint with the insurance company’s grievance officer because this was unacceptable. However, their response was insufficient and they only slightly increased the amount.

It was extremely frustrating as there was no one available to contact, all calls were directed to untrained call centers, and there was no support from any grievance person. This was very disappointing especially after being a customer for 15 years and making my first claim.

Upon learning about Bima Lokpal, I submitted an online complaint, which I found to be a straightforward process.

I meticulously recorded every detail, from the moment of admission to the hospital to the emails I sent to the insurance company. I then compiled a comprehensive day-by-day timeline of events. Shortly after, Bima Lokpal issued a notice to the insurance company, prompting them to reach out to me for further information. After providing them with all the necessary details, the insurance company confirmed that my claim was valid and agreed to reimburse the amount I had requested.

This results in important insights and teachings that I would like to impart.

Initially, you should anticipate the possibility of encountering a scenario where you might not receive your entitled claim despite having extensive insurance coverage, as companies will explore various avenues to potentially reject or delay your claim. (Not all companies engage in this practice, but a significant number do.)

1. Familiarize yourself with the fundamental terms and conditions of your policy beforehand. Understand aspects such as room rent coverage, waiting periods, pre-existing disease waiting periods, inclusions, exclusions of charges, etc. It is essential to study these details thoroughly before purchasing a policy, even if you have held the policy for an extended period without making any claims.
2. Please make sure to thoroughly examine your hospital bill and verify whether the insurance company has rejected any particular expenses for valid reasons.
3. Ensure that your documentation is flawless by organizing and storing both soft and hard copies of all consultation reports, bills, lab reports, etc. in a date-wise manner. This will prove to be invaluable for future reference.
4. If you are dissatisfied with the settlement, you can address your concerns to the Insurance company Grievance department. There is a 50% likelihood that they may assist in achieving a more satisfactory resolution.
5. If you are still unsatisfied, you can visit Bima Lokpal. The entire process of filing a claim and receiving a settlement is conducted online, allowing you to handle everything from the comfort of your own home. This system operates with great efficiency.
6. In the current digital era, it is crucial to consistently send a carefully written email to the appropriate person and sometimes follow up to receive help and find a solution.
7. In case your situation is legitimate, do not lose hope. Seek assistance from a family member, friend, or financial advisor if you are not comfortable with online communication. However, claiming what is rightfully ours as customers is important, and we must assert our rights regularly.
8. Additionally, Bima Lokpal is available to address any and all insurance grievances, including those related to health, motor, and life insurance. Further details about their services can be found on the internet.

Useful links: To file a complaint, make use of one of the available links.

• Council Of Insurance Ombudsman
• Bima Bharosa

Sunil (An Ordinary Common Man, who fights for due Rights!)