5 reasons behind health insurance claims getting denied

Understanding below mentioned reasons can help individuals to decide and maximise the benefits of their health insurance coverage.

Unveiling the top 5 reasons behind health insurance claims getting denied

Below are some of the primary reasons behind health insurance claims getting denied:

1. Non-disclosure of pre-existing conditions

The non-disclosure of pre-existing conditions is one of the primary reasons for claim denials. It is essential to provide accurate and complete information about any pre-existing medical conditions while applying for health policies. This information is vital to assess the risk and determine the appropriate coverage, failure to do so can result in claim denials. Policyholders should always disclose their pre-existing conditions truthfully during the application process to avoid claim denials.

2. Waiting periods and exclusions

Waiting periods are certain durations during which certain treatments or conditions are not covered. Health insurance policies often come with waiting periods and exclusions. On the other hand, exclusions are specific medical treatments or conditions that are not covered under the policy. Policyholders need to be aware of these waiting periods and exclusions to avoid claim denials.

3. Inadequate documentation

Policyholders must provide all the necessary documents, such as medical reports, bills, prescriptions and discharge summaries while filing a claim, as per the policy requirements. Insufficient or incorrect documentation is one of the common reasons for claim denials. Failure to submit the required documentation may lead to claim denials.

4. Policy lapses and non-payment of premiums

It is important for policyholders to pay their premiums on time and keep their policies active. A lapsed policy or non-payment of premiums can result in claim denials. Failure to pay premiums within the specified time can lead to the policy lapsing, where coverage becomes invalid.

5. Claims for non-covered treatments or services

If a policyholder files a claim for a medical treatment that is not covered under their policy, it is likely to be denied/rejected. Health insurance policies have specific coverage limits and exclusions. It is necessary to understand the coverage details and limitations of the policy to ensure that claims are filed for eligible medical treatments and services.