Health Insurance Claim

Yes, medical urgencies can come juts out of the blues, and that is certainly not in our control! You may not be capable enough to prevent something that is related to medical emergencies. In fact, we always gear up for the way to handle them with whatever is feasible for us.

Many individuals get the shock of their life when their health insurance claim gets denied at the last moment by the service providers. Then begin the course of allegations and counter-allegations and all these leads to the growth of a general distrust against the health insurance companies. But how can the hapless patients protect themselves from such last-minute shocks? To start with one should carefully go through all the conditions laid down in the policy and seek full explanation of all ambiguous clauses and terms to avoid claim rejection later on.

There are many factors which can contribute towards the rejection of a claim for health insurance. A proper study of these policies will help the consumer to clear all kinds of hurdles in the process of making a successful claim.

Undisclosed Facts

One of the major contributory factors for denial of a health insurance claim is the non-disclosure or just a partial disclosure of important facts. These facts usually pertain to the existing medical conditions, diseases, income etc. Wrong facts stated on the proposal form at the time of taking out the policy can lead to rejection of a claim. One must understand that hiding or giving incorrect information can have serious consequences in case of health insurance policies. It is a well-known fact the each and every healthy insurance policy operates on the basis of underwriting principles that is inferred from the information provided by the patient party. So, giving out relevant information is very important to ensure that a claim is not rejected in the future.

Excessive Expenditure

There have been many instances when an insurance company has rejected a claim by stating that the patient has undergone an unnecessary medical procedure. The private medical facilities have almost made it a practice to subject a patient to endless medical procedures in pursuit of additional revenues. Now this can take a more serious turn if the medical facility comes to know that the patient is actually paying health insurance premium. The policyholder is always under a false impression that the entire expenses would be borne by the medical insurance company. This kind of irregularities can provoke a medical insurance company to reject a claim. So in his best interests a patient should not encourage the facility to present exaggerated bills. He must be responsible enough to force the facility not to carry out unnecessary medical procedures as that would jeopardize his claim.

Disparities in the Proposal Form

The customers sometimes depend on intermediaries to fill up the proposal forms and this causes some errors to creep in without the knowledge of the policy holder. He might be unaware of the mistakes and dreadful blunders can happen in the declaration form. So if you are buying a health insurance on the basis of inaccurate details then the insurer can reject your claim upon verification of the same. The customer must fill up the declaration form all by himself and submit only authentic documents with the policy. If still there is any discrepancy then that should be informed to the company immediately.

And most importantly, if you are living in one of the 28 EU countries then you should apply for the European Health Insurance Card or EHIC as it ensures state-provided healthcare for the holder of the card. The card is valid in the 28 countries of the European Union along with Switzerland, Norway, Iceland and Lichtenstein. With the help of this card, a person can get medical treatment in another member state at low rates or completely free of charge. The main purpose of the EHIC card is to allow people to continue to stay in a particular country without the necessity to return to the home country for medical care.

Late intimation to the insurer

If you delay informing the insurer about the hospitalization process, that may lead to rejection of the claim. The policyholders who are unable to inform their insurers within the stipulated time frame that is usually set between 24 hours to 48 hours of hospitalization may have nothing to left to retain their medical insurance. Yes, there is no other option other than opting for the claim rejection!

You can see that the reasons for rejection of health insurance claims cannot be multifield, yet they are significant for us. So, it is advised that you must be aware beforehand about the different reasons so that you can effectively distress at the last minute.

As it is said now, are you wondering over the facts to know what all you can do to avoid giving the insurers a valid reason for rejection in the first place? Indeed, many of you are here with the best approach for avoiding rejection of health insurance. Here are the steps that follow!

How do you opt for avoiding claim rejection?

What can be the first step for ensuring that you are on the correct tracks for preventing rejection for your health insurance? Well, you just have to keep in mind that you have to go through all the policy wordings in a detailed manner. Yes, that includes the page of the terms and conditions also. If you are unaware of the exclusions, claim process, deductibles, and other essential critical details, you will end up getting yourself mire confused about opting for the wrong health insurance policy.

The next big thing that you can fill in the good spaces is by filling the form yourself! If you have any doubts while you are opting to fill the forms, you can always consult for the insurer’s suggestions or the agent. Remember, not to get anyone else to fill the form for you. In fact, you can also go for double-checking the insurance claim for accuracy. Indeed, that is a good practice.

You must provide correct information regarding the medical condition. Yes, that is something that must be done without a second thought. That is mostly done in the cases where you want to prevent the claim rejection at any point in time when you are in urgent need of help.

You must not forget to make copies of all the documents that you would be suing while filling up the claim for the health insurance policy. If you do so, it would be easier for the health insurer to provide TPA with reference, if at all it is needed in the future!

Providing all the medical records to the TPA can be an excellent idea for easing things up. If you have the case of incurrent of post-hospitalization costs, providing the details must be carried out within a span of 90 days from the hospitalization date.

If your hospitalization procedure is planned, it would be better to look for the insurer’s approval in advance. However, if that is a case of any medical emergency, you can proceed with the treatment and inform the insurer within the specified time.

In conclusion

It is always essential to get through the exclusions mentioned in the policy as it would give clarity of the prevailing conditions with much wider coverage. Indeed, the best way to deal with the rejections is to look for the ways to deal with claiming rejections and set it according to your reasons. Of course, you can take the help of medical practitioners, TPA, and ombudsmen as and when needed for suggestions and requirements!