Health insurance is a vital financial safety net that protects you from unexpected medical expenses. However, many policyholders face a shocking reality during emergencies—claim rejections. Imagine paying premiums regularly and still being denied coverage when you need it most. The truth is, most claim rejections are avoidable if you understand the common reasons behind them and take preventive measures.
In this blog, we’ll explore the top 7 reasons why health insurance claims get rejected and practical tips to avoid them.
1. Pre-existing Medical Conditions Not Disclosed
Reason:
One of the biggest mistakes people make is hiding their pre-existing illnesses while buying a policy. Insurers rely on honest disclosure to assess risk. If they later discover that you had a pre-existing condition that wasn’t mentioned, they can reject your claim.
How to Avoid:
Always provide accurate and complete health information during the application process. Even if it’s a minor condition like high blood pressure or diabetes, disclose it. Some insurers may apply a waiting period, but honesty ensures your future claims are safe.
2. Policy Lapse Due to Non-Payment of Premiums
Reason:
If your policy lapses because you missed paying premiums, you lose your coverage. Claims during the lapse period will be rejected without exception.
How to Avoid:
Set up auto-debit for premium payments or mark reminders on your calendar. Most insurers offer a grace period, but it’s best not to rely on it. Pay on time to keep your policy active.
3. Treatment Not Covered Under the Policy
Reason:
Every health insurance policy has exclusions—specific treatments or conditions it does not cover. For example, certain cosmetic surgeries, dental procedures, or experimental treatments may be excluded.
How to Avoid:
Read your policy document thoroughly and understand the inclusions and exclusions. Before undergoing any treatment, confirm with your insurer whether it is covered.
4. Submitting Incomplete or Incorrect Documents
Reason:
A claim can be rejected if your documentation is incomplete or incorrect. Missing bills, wrong hospital details, or mismatched personal information can delay or derail approval.
How to Avoid:
Keep all hospital bills, prescriptions, discharge summaries, and identity proofs ready. Double-check the claim form before submission to ensure accuracy.
5. Claim Filed After the Deadline
Reason:
Most insurers have a deadline within which you must inform them about hospitalization or treatment. Delays in intimation can lead to rejections.
How to Avoid:
For planned hospitalization, inform your insurer well in advance. In emergencies, notify them within 24 hours of admission. Keep your insurer’s helpline saved in your phone.
6. Waiting Period Not Completed
Reason:
Many health insurance policies have a waiting period for certain illnesses and pre-existing conditions, usually ranging from 1 to 4 years. If you file a claim during this period, it may be denied.
How to Avoid:
Know the waiting periods for various illnesses in your policy. Plan your treatments accordingly if possible, and purchase insurance early in life to complete waiting periods sooner.
7. Hospital Not in Network for Cashless Claims
Reason:
If you choose a hospital that is not part of your insurer’s network, your cashless claim may be denied, and you’ll have to pay upfront and apply for reimbursement later.
How to Avoid:
Check your insurer’s list of empaneled hospitals before admission. For emergencies, ask the hospital if they can coordinate with your insurer for cashless approval.
Final Thoughts
Claim rejection can be frustrating and financially stressful, but with proper awareness, most rejections can be avoided. Always read your policy document, disclose accurate information, maintain timely premium payments, and keep track of claim procedures. Health insurance is meant to be a shield—make sure yours is reliable when you need it most.