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Steps to Appeal A Health Insurance Claim Denial

If the insurer has rejected your health insurance claim, you need not lose hope. Click here to know how you can appeal against the rejected claim application and reapply.

  • Oct 28, 2021

Dealing with a health issue can be daunting for the person suffering from the illness and their family members. Having a health insurance cushion can provide immense relief in such a situation, knowing that the insurer will cover the treatment cost. However, what if your health insurance claim gets rejected? It may lead to immense stress.

Health insurance claim rejections are real, and the insurers reject the claim application for several reasons. Generally, when the insurance companies deny the claim, they inform the applicant about it and the reasons for rejection. If the insurer has rejected your claim, you need not lose hope. You can appeal against the rejected claim application and reapply.

How to appeal if your health insurance claim is denied?

Know the reason or claim rejection

Before you file an appeal, you must know the exact reason for claim rejection. Generally, the insurance companies reject the claim application because of the following reasons:

  • You have raised a claim for a disease/treatment option that is not covered under the policy.
  • Your policy has expired.
  • You have not provided sufficient details to support your claim in the application form.
  • You have not provided enough proof/documents as required.
  • You have filed a claim for someone who is not covered under the policy.

Rectify and Reapply

Once you know the exact reason why the insurance company has rejected your claim application, do the necessary changes, and file the claim again. For example, if the reason for rejection is incomplete details provided in the application form or insufficient documents provided, provide the necessary documents and reapply.

It is a good idea to contact the insurance company to know if the additional details or documents you have provided are sufficient before re-submitting your claim application form.

However, you must know that if the reason for claim rejection is ‘claim raised for expired policy’ or ‘claim raised for issues not covered under the policy scope’, there is no way you can get the policy benefits.

Approach an Ombudsman

An Ombudsman is an official appointed by the insurance company to help the policyholders with their complaints against them. According to the Insurance Act, 1938, you can approach an ombudsman for complaints relating to claim settlement, the difference in premium charges, violation of policy terms or policy terms are not clear.

The Ombudsman acts as a mediator between the policyholder and the insurance company and helps both parties settle the dispute. The Ombudsman verifies the facts and provides a fair recommendation.

When you approach the Ombudsman, make sure that you keep all the bills intact to support your claim. It is better to have copies of the policy documents, payment receipts, and KYC documents.

Write an appeal letter to the insurance company

One of the easiest ways to file an appeal against a rejected health insurance claim is to write an appeal letter to the insurance company with proper facts. The letter or email should contain necessary details, including the purpose of writing the mail/letter.

You must also mention why you availed of this policy and the medical condition you have. Include the treatment plan recommended by your doctor and proof of medical prescriptions. It will help the insurer reconsider your appeal against the rejected claim.

Final Word

Health insurance claim rejection is common. You need not worry if your claim gets rejected. Understand the reason for denial and take appropriate corrective measures before you reapply. If your claim is legitimate, the insurer will surely consider your appeal and approve your claim.

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Ref. No. KLI/22-23/E-BB/2435


- A Consumer Education Initiative series by Kotak Life

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