Summary of this article
· Claim rejection can deplete retirement savings
· Identify reasons for cashless and reimbursement claim rejection
· Approach IRDAI and consumer forums for legal support
Nowadays, many insurance companies hire third-party investigation agencies to carry out detailed scrutiny before processing any claim. Such third parties often use unorthodox ways for verification. Recently, an insurance claim was rejected just because the Google timeline of the patient did not match the hospital visit date and time as mentioned in the claim document. Though later, the case was resolved after the claimant took legal recourse.
If your health insurance claim is rejected, then you must take the right steps to avoid delay and clear all the ambiguities. Here are some important steps that you should take when your health insurance claim gets rejected.
Ask Insurer Why Claim Was Rejected
At the time of hospitalisation, you can either request a pre-hospitalisation approval and get a cashless claim, or if you get hospitalised in an emergency and didn’t have time for a cashless claim, then you can apply for a reimbursement later on. If your cashless claim is rejected, then you can request the insurer to furnish the reason for the same.
In most cases, the cashless claim rejection happens due to document-related problems, and the case is resolved very quickly.
On the other hand, if your reimbursement claim is rejected, then you may ask your insurer to provide the reason for it.
If the insurer asks you for additional documents, then you should provide them immediately. If the claim is rejected for a reason which is not satisfactory to you, then you can go to the next step.
Appeal To The Insurance Company To Reconsider The Claim
If your claim is rejected, you can make an appeal to the insurance company to reconsider the claim while citing a valid reason why your claim should be accepted. You can provide policy wording to support your claim and take the help of the hospital’s insurance desk to arrange supportive documents to make your case stronger.
Escalate The Case To A Higher Authority
If the insurance company is not ready to consider your claim despite your appeal, you can escalate the case to their grievance cell. Provide all the documents they ask for and try to get the claim approved. The grievance cell usually resolves the case in a time-bound manner. However, if your claim is again rejected and the reason for rejection is not satisfactory to you, then you may approach the Grievance Redressal Forum (GRF) of Insurance Regulatory and Development Authority of India (Irdai)
Approach Irdai With Your Complaint
When approaching GRF-Irdai, you must mention all the conversation details that happened with the insurance company and explain your point why the claim rejection is inappropriate. Irdai allows both parties to present their side of the story before it gives the verdict. If you win the case, Irdai may also direct the insurance company to give you compensation for the delay and mental harassment.
When approaching Irdai, you may simultaneously approach the consumer forum as well to ensure that, in case the regulatory body misses your point of view, it can be duly addressed in the consumer forum. You may also take the help of an insurance expert to avoid your claim from being rejected.
The author is an independent financial journalist
