Health insurance is meant to provide financial security during medical emergencies. However, one of the most frustrating experiences policyholders face is when their health insurance claim gets rejected. Imagine paying premiums year after year only to be denied coverage when you need it most. Unfortunately, this is a common problem that leaves many families stressed and financially drained.
In this detailed guide, we’ll explain the top reasons insurance claims are rejected, how you can avoid these mistakes, and what steps to take if your claim is denied. Understanding these reasons will not only save you time and money but also help you stay prepared for emergencies.
Why Do Health Insurance Claims Get Rejected?
Health insurance companies operate under strict terms and conditions. A claim is approved only when the request aligns with the policy’s coverage guidelines. If the insurer finds any discrepancy, missing information, or policy violation, the claim may be denied.
The rejection could be due to policyholder errors, hospital miscommunication, or the insurer’s rules. Knowing the most common reasons for rejection can help you avoid costly mistakes.
Top Health Insurance Claim Rejection Reasons
1. Non-Disclosure of Pre-Existing Diseases
One of the biggest mistakes policyholders make is hiding or failing to declare pre-existing medical conditions such as diabetes, hypertension, asthma, or heart problems.
- Insurance companies require full disclosure of medical history when purchasing a policy.
- If you hide a condition and later raise a claim related to it, the insurer has the right to reject your claim.
👉 Tip: Always declare your medical history honestly, even if it increases your premium. Transparency ensures smoother claim approval.
2. Claim During Waiting Period
Most health insurance policies come with a waiting period, usually ranging from 30 days to 48 months depending on the condition.
- For example, maternity coverage often has a waiting period of 2–4 years.
- Claims filed before this waiting period expires are automatically rejected.
👉 Tip: Understand your policy’s waiting period terms carefully before planning any treatment or filing a claim.
3. Policy Exclusions
Every health insurance plan has exclusions – treatments, conditions, or expenses that are not covered.
Common exclusions include:
- Cosmetic surgeries (unless medically necessary)
- Dental procedures (unless accidental)
- Alternative therapies are not recognised by insurers
- HIV/AIDS or STDs in some plans
- Injuries from hazardous activities
👉 Tip: Read the policy document thoroughly to know what is covered and what is excluded.
4. Incorrect or Incomplete Documentation
Many claims get rejected simply because the paperwork is incomplete or incorrect. Missing hospital bills, incomplete claim forms, unsigned medical reports, or mismatched details (like name spelling errors) can lead to denial.
👉 Tip: Double-check all documents before submission. Ensure hospital and insurer forms are filled correctly.
5. Lapsed Policy Due to Non-Payment of Premium
If your policy is not active because of non-payment of premiums, the insurer will not process any claim. Even a delay of one day can result in a lapsed policy.
👉 Tip: Always set reminders for premium payment dates or opt for auto-debit options to keep your policy active.
6. Treatment at Non-Network Hospital (Cashless Claims)
In case of cashless claims, insurers generally require you to avail treatment from a network hospital. If you choose a hospital outside the network, your claim might be rejected or converted into reimbursement (with stricter checks).
👉 Tip: Always check if your hospital is part of your insurer’s cashless network before admission.
7. Mismatch in Policy and Claim Details
If there is any mismatch in the claim form, such as a wrong policy number, incorrect patient details, or hospital admission dates that don’t match, insurers may reject the claim.
👉 Tip: Cross-verify all details in the claim form with your policy documents and medical records.
8. Non-Disclosure of Lifestyle Habits
If you smoke, drink alcohol regularly, or have other lifestyle-related habits and fail to disclose them at the time of buying the policy, your insurer may deny claims related to those conditions.
👉 Tip: Be truthful about lifestyle habits. While premiums may rise, it ensures claim approval later.
9. Experimental or Non-Recognised Treatments
Insurance companies generally do not cover experimental or unproven treatments. Claims related to therapies not backed by medical guidelines may be rejected.
👉 Tip: Before undergoing treatment, confirm with your insurer whether it is covered.
10. Fraudulent or Inflated Claims
Some people submit fake or exaggerated bills to increase claim amounts. Insurers investigate such cases and reject claims if fraud is detected. In severe cases, legal action may follow.
👉 Tip: Always provide genuine and transparent documents to avoid blacklisting.
Other Common Reasons for Rejection
- Delay in informing the insurer about hospitalisation.
- Hospitalisation for less than 24 hours (except daycare procedures).
- Claiming for routine health check-ups not covered by the policy.
- Multiple claims filed simultaneously for the same treatment under different policies.
How to Prevent Health Insurance Claim Rejection
To reduce the chances of rejection, follow these steps:
- Disclose all health details honestly while buying the policy.
- Understand the waiting periods for specific treatments.
- Read exclusions carefully to know what is not covered.
- Maintain updated records of hospital bills, prescriptions, and medical history.
- Pay premiums on time to keep your policy active.
- Choose network hospitals for cashless treatments.
- Notify the insurer immediately in case of hospitalisation.
- Keep claim forms accurate and error-free.
What to Do If Your Health Insurance Claim Is Rejected?
Even if your claim is rejected, you still have options:
- Ask for a written explanation – Insurers must provide a valid reason for denial.
- Submit missing documents – Sometimes, rejection is due to incomplete paperwork.
- File a grievance with the insurer – Every insurance company has a grievance redressal cell.
- Approach the Insurance Ombudsman – If unsatisfied, you can escalate your case to the Ombudsman.
- Seek legal help – In rare cases, you may have to approach consumer courts for justice.
Conclusion
A rejected health insurance claim can cause immense stress, especially during medical emergencies. However, most rejections happen due to avoidable mistakes such as incomplete documents, non-disclosure of health conditions, or ignorance of policy terms. By being proactive, transparent, and well-informed, you can significantly reduce the chances of claim denial.
Remember, health insurance is not just about paying premiums—it’s about understanding your policy inside and out to ensure peace of mind when you need it the most.
Frequently Asked Questions (FAQs)
1. Can I get my rejected health insurance claim approved later?
Yes, if the rejection was due to missing documents or technical errors, you can resubmit with corrections.
2. How long does it take to settle a health insurance claim?
Generally, cashless claims are settled within 24–48 hours, while reimbursement claims may take 7–15 working days.
3. Can I claim treatment expenses for pre-existing conditions?
Yes, but only after the waiting period is completed as per your policy terms.
4. Will my health insurance cover alternative treatments like Ayurveda or Homoeopathy?
Some insurers cover AYUSH treatments, but only in recognised hospitals and within limits. Always check your policy terms.
5. What should I do if my claim is rejected unfairly?
You can escalate the issue to the Insurance Ombudsman or file a consumer complaint.
