Reasons Policyholders Face Problems when Recovering a Medical Emergency Amount from an Insurance Company?

Estimated Reading Time: 3 minutes

People sign up for health insurance schemes to avail policy benefits in emergency-like situations. Medical insurance companies offer both individual and family coverage policies. Sometimes, employers offer insurance packages as incentives. Even custom loyalty rewards these days are medical insurance schemes.

Health insurance plans are normally classified into several categories so that people of every ages group can benefit from them. Some of the common categories in this list are:

  • Hospitalization
  • Family floater health insurance
  • Pre-existing health cover plans
  • Health insurance plans for senior citizens
  • Maternity health insurance
  • Daily hospital cash benefit plans
  • Critical illness plans
  • Disease-specific plans
  • Proactive health insurance plans.

The most important aspect of a medical insurance is the payment facility i.e. how will the insurance company pay the amount of claim, the most common type is reimbursement plan in which the amount of treatment spent is taken as the reimbursement from the insurer. Some countries have cashless facility in which the insurer directly pays to the network hospital the amount and the hospital doesn’t ask customers for payment.

Troubles policyholders often face

Most medical insurance policyholders pay their annual premium with the faith and hope that when any medical emergency situation will arrive, the medical insurance company will brace the cost up to the policy’s limit and will be there to support them in the need of the hour. But there can be times when the insurance company might refuse to settle claim and deny their contract of liability to pay the hospital on behalf of the customer.

Why does it happen?

Your claim can be rejected for a laundry list of reasons; most common among them are:

  • Incorrect information – when you apply for a medical claim, the first and foremost thing to bear in mind is that the information of the patient such as his name, street address, contact details must be accurate. All other necessary information should also be correctly provided as in most cases the claim is denied due to incorrect information or lack of information.
  • The Spelling of names is incorrect. You can’t be more wrong if you think correct spelling is not that important.
  • You have provided correct information but address and contact information elsewhere is incorrect. Insurance providers tally information.
  • The Policy number is missing or invalid

Avoid these mistakes at all cost if you want the reimbursement process to be smooth and hassle-free.

The claim procedure

There are certain steps to be followed by the policyholder when applying for the claim. It’s hard to tell the exact procedure as different providers follow different procedures. The exact procedure would be provided by the insurance company at the time of policy.

  • Inform the insurance company immediately at the time of emergency
  • Seek treatment in the network hospital only
  • Fill the required claim form accurately
  • Attach all the essential documents, reports and bills

In other words, do all the needful so that the chances of mistakes exponentially go down.

Understand the coverage 

The insurance company is not always to be blamed. In fact, I’d say 9 out of 10 times they cooperate with customers for the fear of losing them. Sometimes, the fault lies with the policyholders who don’t read the policy well enough and later complain that they have been unfairly denied the full coverage.

Here’s a small list of things excluded from the coverage

  • At the time of buying a policy there are certain things that are excluded from the coverage and mentioned in the terms and conditions. The medical insurance company is not responsible for the claim on such excluded incidences
  • Excluded hospitals
  • Certain diseases
  • Death due to homicide or suicide
  • Lapsed policies – a lapsed policy is the one whose premium is submitted beyond the due date. Such policies pay no claim and would be rejected or denied. Always pay the premium always before the due date to avoid such incidents from occurring.

A final rundown

Here are the ways to prevent rejection or denial of your medical insurance claim:

  • Double check the information of patient, disease, hospital details and other insurance information while filing the claim form.
  • Get your concern clear from the insurance company.
  • Follow the claim procedure accurately.
  • Renew your health insurance policy before the due date to avoid any mishap.
  • Submit the report of your pre-existing diseases to the medical insurance company with complete details.
  • Always keep copies of documents submitted to the insurance company for future reference
  • Submit the claim request much earlier in case of pre-planned hospitalization
  • Read all the terms and conditions of the policy at the time of buying it.

Most importantly, don’t get into a brawl if your claim is rejected. Be calm and take legal recourse. Submit an application for reconsideration of the company with the necessary documents to convince them that your claim is genuine.

Send a formal application to the company for reconsideration of your claim and attach all relevant documents along with the application.

You can also Appeal multiple times for the claim validation. There’s no limit. If all means fail and you are sure you haven’t made a mistake, take the legal route.




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