Definitely, a health insurance claim can be rejected and or refused on a number of grounds !
Common reasons for health insurance claim rejection are –
- The foremost reason why a claim can be rejected is when it doesn’t qualify as per the policy terms. An example of this could be if the hospitalisation is not for 24 hours. Unless it is an approved day care treatment, the hospitalisation has to be for a minimum of 24 hours. Another example may be, if the hospital doesn’t have the minimum of beds as specified under the health insurance policy
- Your policy has a list of exclusions ( which policy doesn’t !) For example, if the claim is arising out of consumption of alcohol or any narcotic substance. On such exclusions, the insurance company has the right to reject the claim
- Every health insurance policy has a specified time by which intimation of the claim and submission of the claim needs to be done. If there is any delay on either of the clauses, the claim can be denied for payment.
- In case you commit a fraud or its committed on your behalf, the insurer has a right to reject your claim
- The reason for rejection of a claim can include if there was a mis-declaration, non-declaration or partial declaration in the proposal form at the time of taking the health insurance policy. This is particularly relevant to retail health insurance policy
- The claim can be denied in case of non-cooperation with the insurance company. For example, to physically check the patient and the treatment, the insurer deputes an investigator. Frauds happen when another person impersonates the policyholder. It is deemed non-cooperation if the investigator is not allowed to verify these details at the time of visit.
I will recommend the following that you can do to challenge a rejected claim. Please follow this link to understand how you can challenge a claim that has been rejected or only partially settled. This includes representation to the third party administrator or the insurance company as well as legal options that you have