why your health insurance claim got rejected \partially approved

[Vasuki]

edit will come , suggestions are appreciated if you went through any personal experience



After all you bought your health insurance and now even you read most of clause and aware of many here are few most common ground on which health insurance claims are partially passed in 90 % cases by company not out right rejected because they know customer will go to IRDA
so they pass partial claim stating some sub limit or clause so that most educated fools thinks " jo mila usme khus rho " and never care to read between the line used against them


1 reasonable and customary charges clause - when we talked about buying insurance at zonal level policy , say at village address in bihar has heart surgey costs average 2 lakh but you bought insurance at village address & went to delhi for surgery hence company will pay max 2 lakh no matter surgery costs 2.5 lakh . sometimes u have to pay 20 % co pay

solution is - buy good reputation company which does care about their reputation and not notoriously popular for claim partial rejection
choose agent who will help than ditch
approch ombudsman for insurance oic




2 hospitalization not required - in former case u atleast get some claim but in this they totally out reject all claims . as i told you any claim required 24 hour hospitalization to claim to be valid hence one day OPD gets out right rejected . with evolution and modernization most surgery are less than day thing

say u got dengue and got hospitalized company will say u need not to be admitted could be treated via OPD
so what would you do
firstly - get doctor in writing that u need hospitalization and OPD will not do the job
attach this with documents
if still rejected what else than complaint to ombudsman

or you can choose for day care policy which covers OPD treatment

3 discrepancies in documentation - some document you required for reimbursement claim like
original claim form with sign
valid id
doc prescription suggesting treatment in hospital
doc prescription advising tests , meds & consultation
pharmacy bills , ambulance receipt , FIR if required in accident

this usual kicks in time of frauds not genuine cases



4 non disclosure of material facts - if you dont disclose you facts like smoking , dibeties , alcohol or any past surgery which has impact on premium then your claim might get rejected and you cant do anything about it ... be honest
even if you any surgery years ago disclose it


5 NOT understanding exclusions - like
30 day waiting period
war , chemical or biological attack
dental and maternity treatment
infertility treatment
adventure sports , plastic surgrey , weight reduction or gender surgey
etc




now your cashless claim is rejected you can apply for reimbursement
if still rejected you can complaint at BIMA BHAROSA platform
1 is call
2 is complaint at portal
3 is IRDAI Escalation
4 CIO ( council of insurance ombudsman ) 17 cities has offline process u can have online hearing too . they solve within 3 months
5 consumer court ( national consumer portal or e- daakhil portal )
6 court

 

[anujdit]

Other reasons:

1. Room Rent approved by Insurance company and Room Rent charge by Hospital. Sometimes Hospital charge 15k per day by Insurance company approve 11k for example by saying that we have agreed rate with hospital for 11k. In such cases, pay 4k to hospital and claim as reimbursement from insurance company

2. Capping on particular treatment (Cataract for example): Check with Insurance company about upper limit before treatment

3. Check on Room Rent eligibility. Better to get policy with no limit on room rent.

 

[the_dark_knight]

4 non disclosure of material facts

4 non disclosure of material facts - if you dont disclose you facts like smoking , dibeties , alcohol or any past surgery which has impact on premium then your claim might get rejected and you cant do anything about it

janab , iss case mein claim hi nhi reject hota h, policy se bhi hath dhona padta h,
aur toh aur IRDAI bhi goli maar dega,
paid premium ka ek paisa wapas na hoga

This ombudsman is different from RBI ombudsman

 

[David]

Avoid purchasing Aditya Birla Health Insurance policy. Protect your hard earned money and consider other trusted options. claim ID 1122485038509.We have an Aditya Birla health insurance policy. My mother was hospitalized on January 22nd and discharged on January 28th. Our hospital bill was 4,37,220. That hospital was not the network hospital in Aditya Birla. We submitted all documents on time within 15 days of discharge. But despite this, my claim was initially rejected on April 16, 2024, citing "late document submission." It was later found to be an error on the agent's part. After reopening, 9 queries were raised; the 4th investigation was done, and we promptly addressed each one. Now, on August 27, 2024, the company claims we are unable to submit additional documents, then rejecting our ₹4,37,220 claim again. This is unacceptable and unfair. We trusted #AdityaBirlaHealth with our health, not expecting such a frustrating experience!, especially when all required documents were submitted on time.

 

[David]

 

[David]

 

[the_dark_knight]

yes agreed with you, although I don't have any claim experience to share with aditya birla, but had taken some top-up policies from them before. Their support staff customer service is pathetic, no resolution provided to me when raised issues regarding wrong info registered in their system against my policy. That time I understood, if this is their standard on simple non-claimable complaints, what would customers face at the time of claims.

 

[the_dark_knight]

View attachment 67401

Are you pursuing this with IRDAI now?

 

[David]

Yas,i also register complaint on bima lokpal

Are you pursuing this with IRDAI now?

It seems like you're describing a frustrating experience with customer service where the team lacked understanding of the issue. They registered your complaint but claimed it was resolved the next day without actually addressing the problem. This kind of poor service can be frustrating, especially when the root cause remains unresolved.

 

[David]

 

[the_dark_knight]

View attachment 67489

Great. Once you have all of this sorted and get a first-hand experience yourself on how to fight claims up to the highest insurance authority, Do create one thread here so that fellow TFians can highly benefit from your practical learnings

 

[David]

View attachment 67402

The first rejection was due to late submission, and the second was because additional documents were not submitted. You noted that it's unlikely anyone would deliberately cause such issues, especially after paying a significant amount at the hospital. This kind of situation can be really stressful, particularly when you've already made a substantial payment and are trying to follow the process correctly.