It is possible for health insurance claims to be rejected. Two major reasons for the rejection of the claim are procedural issues and substantive issues.
Procedural issues may include not providing the correct or complete documents (e.g. not supplying the discharge summary, original invoice or doctor prescription may lead to the rejection of your claim) or a delay in informing the insurance company about the claim and in obtaining approval to proceed with treatment (notification should occur within 24-48 hours of admission in an emergency and 3-7 days prior to a scheduled surgery).
Substantive issues may include providing inaccurate information such as your name, date of birth or policy number. If any of these details do not match what is on your identification or in your insurance records, it may lead to a rejection.
1. Policy & Medical Grounds
Non-Disclosure of Previous Conditions (NDC): If you fail to provide information on a specific condition (example - diabetes, blood pressure) when obtaining your policy, your claim for a condition related to your pre-existing condition may be denied by the insurance carrier on the basis of "NDC".
Waiting Periods: Most first time policies have a 30-day waiting period (except for accidental injuries) and then there are additional waiting periods for some pre-existing conditions ranging from 2 - 4 years.
Permanent Exclusions: Treatment exclusions such as cosmetic surgery, dental surgery (unless due to an accidental injury), or experimental treatments will generally be excluded under your policy.
No Medical Necessity: If the provider's medical staff determines that the treatment could have been accomplished as an even out-patient (outpatient) service rather than in-patient (spending time at the facility) for more than 24 hours, the evidence provided by the attending physician will need to be gathered in order to validate that the treatment is covered by the insurance provider before payment is made.
2. Can it be Denied After a Pre-Authorization?
Yes, There is No Guarantee Against Cashless Pre-authorization.
An insurer may authorise payment for surgery, however, later the provider submits the billing codes by the insurer where the billing codes do not match the procedures provided.
New medical history arising during the hospitalisation, that was not disclosed prior to admission to the hospital by the providing physician or facility, can prompt a revocation of the pre-authorisation.
In this situation, you are obligated to pay for your claim and will submit a reimbursement request after the claims have been completed when filing for reimbursement.
If your claim is denied don't panic! You can appeal .
Look at the denial - Review the denial letter carefully for the specific reason/section of the insurance policy that was cited.
Provide Necessary Documents - If your denial was due to missing documents; simply send in the correct documents.
Appeal Internally - Contact the Grievance Redress Officer (GRO) and ask for the decision to be re-evaluated with a letter from a doctor stating the need for the treatment.
Escalate to the Ombudsman - If your claim remains unresolved after 30 days; you can also file a complaint with the Insurance Ombudsman, an impartial agency set up by the Government to settle disputes.
