Why Cashless Health Insurance Claim Got Rejected? Here is what might have happened in your case
Policyholders diligently pay the premium amount every year in hopes that if a medical emergency strikes them, the policy would cover the expenses and take the burden off their shoulders. And when the insurer rejects their claim, the policyholders are left devastated. While there is no way out of this situation, it can always be avoided. By knowing and assessing the conditions that may lead to a cashless claim rejection, you can take effective measures and fend off difficulties.
Here are a few reasons your cashless health insurance claim may get rejected whether it's an individual or family floater or a corporate mediclaim policy:
1- When the Pre-Existing Diseases are Not Disclosed- Health insurance claim process is all about building a trust with insurance companies and taking them in a confidence that no fraudulent activities are practiced. Hence, a breach in trust gives the insurance company full rights and reason to reject the claim. Many policyholders do not disclose their PED (Pre-existing disease or condition) at the time of buying health insurance. And when they file a claim, the insurance company goes through the entire treatment and disease history. This is when the insurer finds out that the disease or condition existed before the policy was bought. For example, a policyholder doesn't disclose that he has been diagnosed with diabetes. So, if he gets a stroke because of diabetes, they will not be eligible for a cashless claim.
2- The Treatment is Still in the Waiting Period- Most policies have a waiting period on certain diseases and illnesses that have a high rate of occurrence such as ENT disorders, hernia, etc. And if a policyholder opts for a cashless claim while the treatment of the disease is still under the waiting period, the claim gets rejected.
For example, if there is a 2-year waiting period on the treatment of kidney stones and the policyholder opts for a cashless claim, their claim will be rejected.
3- The Sum Insured is Exhausted - When the policyholder exhausts the total sum insured and opts for a cashless claim, their claim is bound to get rejected. Hence, every time there are some medical expenses coming up, it is important to check whether or not any balance is available.
4- The Policyholder Doesn't Choose a Network Hospital- All insurance companies create a preferred partnered network known as PPN. It consists of all the hospitals that the insured can avail cashless treatment at. The insurance company then pays the treatment amount directly to the hospital.
Since the cashless treatment facility is only available at the network hospitals, the insured cannot avail a cashless treatment if they end up going to a non-network hospital in case of an emergency or because of the lack of this information.
5- The Insurance Company Needs More Information- The insurance companies authorize cashless treatment when the insured is able to establish trust. However, if the insurance company wants more details on the policyholder's medical history, it can ask the claimant to file a reimbursement claim. In this case, the policyholder pays the medical expenses out of their pocket at the hospital, and later files a reimbursement claim with all the supporting documents.
By understanding what can lead to claim rejection, you will be able to make the right policy decisions and ensure that your claim is never rejected. So, be wise so that you can use the policy when you need it, otherwise, there is no point of having one.
Anuj co-founded SureClaim to fix the broken claim experience of insurance customers. He believes technology can play a major role in empowering customers. His understanding is shaped by his decade long stint in healthcare and health-tech companies.