Why Would Health Insurance Deny a Claim? Whenever you purchase a health insurance cover, you are under the assumption that the insurance company will come in during such medical crises and clear your bills. Most policy holders however are shocked to realize that their claim is not accepted. It is best to have a knowledge on the general causes of refusals so that you can eliminate needless heartbreaks. There are two reasons, which we explore in this blog post, why insurance claims are denied and how to raise the probability that the insurance claim will be approved.
Common Reasons for Claim Denial ● Failure to disclose Pre-Existing Conditions: The failure to report the pre-existing medical conditions during purchase of the policy is also among the most common reasons that lead to denial of claims. Such conditions as diabetes, high blood pressure, previous surgeries, even though they might be considered minor, are considered as material information. When the insurers find them after a claim, they usually reject it citing non-disclosure. ● Waiting Period Uncompleted: Waiting periods are associated with almost every health insurance plan. In some diseases or even known conditions the coverage is only valid after some certain period- it might be 1, 2 or may be more years. Claiming anything before this time is likely to be thrown away. ● Treatment or Procedure Not covered (Policy Exclusions): All the policies come with a list of exclusions - treatments or conditions not covered. These may be cosmetic surgery, some dental surgery, alternative medicine, or even some day care/OPD surgery. Claims made on omitted treatments are virtually rejected. ● Incomprehensive or Substandard Documentation: Insurers demand paperwork, with extensive documentation: hospital bills, prescription, discharge summary, diagnostic report, proof of identification etc. Claims are frequently denied by insurers in case documents are lost, names/ages do not match, or because of some errors. ● Policy Lapsed / No Premiums paid / Not in covered condition: Without renewing the policy, or paying the premium, which lapses, or there is a lapse of time, the insurance ceases to be in operation. Any claim in a lapsed or inactive policy will be rejected. ● Late claim filing or omitted steps (e.g. Pre-Authorization):
Most insurers require that when the hospitalisation or treatment is to be claimed, it must be intimated within a given period (e.g., 24 hours after admission in case of an emergency). The failure to present the required pre-authorizations or the inability to submit them on time can be taken as a refusal. ● Medical Necessity/Treatment Justification Problems: Insurers occasionally assess the necessity of the hospitalisation or treatment whether it was medically necessary. In case your process is considered as elective, avoidable or not a necessity that is plainly needed, the insurance company might refuse to pay the claim based on non-medical necessity. ● Going above Policy Limits (Room Rent Caps, Sub-limits, Benefit Limits): Sub-limits may be imposed by the health plans such as a limit on renting rooms, on specific procedures or limit on amount of coverage. In case a claim claims beyond such limits, insurers can decline it or pay it in part.
How to Avoid Claim Rejection — Tips from Claimnikalwao At Claimnikalwao, we believe awareness and careful preparation are the keys to making your health insurance work when you need it. Here are simple practices to help avoid common pitfalls: ● Always be completely honest about your medical history, even the most minor conditions you might have had, it will always pay off. ● Learn your policy: Be conversant with waiting periods, coverage inclusions and exclusions, sub-limits, room-rent caps and any other specials. ● Maintain full and correct documentation: hospital bills, prescription slips, discharge notes, and diagnostic reports- check names, dates and signatures. ● Make claims in time and go through the necessary procedures (such as pre-authorization or prior intimation towards planned hospitalization). ● Make sure you have a continuous cover- do not allow the lapses in payments and take out fresh cover in time.
Final Thoughts A denied health insurance claim isn’t always due to unfair or arbitrary decisions. Often, it stems from misunderstandings, oversight, or simple errors. By being proactive, honest, and attentive to policy details, you can significantly reduce the risk of rejection. At Claimnikalwao, our goal is to help policyholders navigate health insurance — understand what’s covered, what’s not, and how to maximize your chances of a smooth claim settlement. Follow these practices to ensure your insurance truly works when you need it most.
