Summary of this article
Health insurance claims cannot be denied for missing old medical reports.
Cashless claims need no documents; reimbursement requires complete treatment records.
Half of claims face delays due to absent medical history verification.
Organised medical files speed insurer checks and reduce claim-processing queries.
There is no requirement or condition in a health insurance policy that old test reports, prescriptions, or treatment histories must be produced. The past treatment history and other particulars will be recorded by the hospital where the insured is admitted for treatment, and further courses of treatment will be decided accordingly by the treating doctor. “The claim cannot be delayed or denied for the reason that the insured is unable to produce the old test reports or histories,” says Hari Radhakrishnan, expert, Insurance Brokers Association of India.
In respect of cashless hospitalization, the insured may not come into the picture, as the transaction happens between the hospital and the third-party administrator (TPA)/insurers. “The insured need not submit any documents. Only for reimbursement claims, the insured has to collect from the hospital, settle dues, and then claim for reimbursement, where the insured needs to be well organized with all treatment records, discharge summary, bills, receipts, and other documents,” says Radhakrishnan.
Organised Medical Files Speed Approvals
Around 50 per cent of medical claims are kept on hold due to the non-submission of past medical records. “This has become a standard query raised by almost all insurers, often even when the previous reports or history may not be directly relevant to the current claim. As a result, insurers spend additional time verifying medical backgrounds, which slows down the overall claims process,” says Anita Teli, Chief Compliance Officer, Probus.
Organised Medical Files Speed Approvals
It is good to have a well-organized medical file for one’s own reference and a backup. Producing documents will not avoid rejections caused by missing or undisclosed health information. If there has been any mistake made in the rejection of a claim by the insurer, that can be appealed against by producing documentation for rebuttal reasons.
“For example, if the insurer alleges that diabetes was not disclosed, but if the insured has a test report that shows that the diagnosis for diabetes was done after taking the policy, then he can rebut the assertion of the insurance company that diabetes was not disclosed while taking the policy, as the insured cannot disclose something that was not yet diagnosed when the policy was being taken,” says Radhakrishnan.
“A single, well-organised and updated medical file with all the reports and prescriptions in one place helps insurers verify health history quickly, reduces repeated queries and speeds up the claim approval process,” says Teli.
Policyholders thus must keep all diagnostic reports, prescriptions, discharge summaries, medication lists, and long-term treatment records in one place (either physical or digital). Having this list ready prevents delays and reduces the risk of claim denial due to missing or incomplete information.
