What Are The Likely Conditions Under Which Your Health Insurance Claim Can Be Denied?


4 min read

Insurance is a subject that many people find difficult to comprehend. And many times, the lack of knowledge becomes the causes for health insurance claims being denied. Let’s read more.

Every time you see an advertisement or read an article about insurance, it mentions that the investor should read the policy document clearly before buying the policy. However, most people have this habit of ignoring their health insurance policy papers. Some people ignore thorough reading of the terms and conditions due to lack of understanding of insurance jargons, while others may ignore due to lack of attention. Such ignorance leads to carelessness, which in turn leads to denial of health insurance in many cases.

Some people, whose claims were approved, might think that raising a claim is smooth, while those whose claims get rejected might feel that the insurance claim process is very harsh and complicated.

Thus, it is necessary that an insured person should know the reasons for which claims can be denied. At the same time, it is equally important to understand the preventative measures that can be applied so that the claim does not get rejected. If the insured can persuade the insurer that the raised claim is legitimate, they might re-consider the claim even after it was rejected.

Moreover, it is equally important to check the health insurance claim ratio of the insurer from which you are planning to buy the policy so that you can choose an insurance company offering a good health insurance claim ratio.

On what instance can health insurance claims get rejected?

In this blog, we are discussing the reasons why claims get denied.

5 Primary Causes For Health Insurance Claims Being Denied

If a health insurance claim is denied, you have to understand the reason why it is denied. Only then you could seek appropriate steps.

Below are some of the leading causes of denial of health insurance claims:

  • Know the Claim Procedure – The first and the most important aspect of a claim procedure is to know the process well.  When you know the claim procedure in and out, you can ensure that you do not make such mistakes to get your claim denied. After all, a health insurance plan is a contract between the insurer and the insured. Thus, knowing each and every element of this contract helps in raising perfect claims. Also, many times the policyholder fills the health insurance claim form improperly. This also leads to claims getting nullified. Clarifying doubts reduces the likelihood of claims getting rejected.
  • Concealing information on already Existing Conditions –  In many cases, when people buy a health insurance policy, they consider the treatments that are impending. However, they tend to neglect the diseases that are already prevailing. Some people even try to conceal the information related to already existing diseases that they are suffering from. In such a case, it is very likely to impact your health insurance claims status and it might get denied. So, if you do not inform the insurer about the diseases that you are suffering from such as hypertension, diabetes, etc. the insurer may not approve claims for any related treatment.
  • Duration Of Policy – Most health insurance policies are active for a year after which it expires. Thus, it is necessary to renew the policy before expiration. And if you do not renew the health insurance policy and it ends, you may not be able to renew it again. Also, if your policy expires and you file for a health insurance claim settlement process after the policy has ended, it will not be approved. So, you should keep a tab on when your health insurance policy expires.
  • Waiting Period – Every health insurance plan has a waiting period. Waiting period is the time that a policyholder has to wait before being able to avail the coverage of the health policy. For example, Most insurers levy a two year waiting time before the insured could avail coverage on already existing diseases. Some policies have 2-3 years waiting period before one could avail pregnancy coverage.  All such waiting periods depend on the terms and conditions of the insurer. So, you must ensure that you do not raise a health insurance claim letter for an illness that is still under waiting period so that it doesn’t get rejected.
  • Exclusions – Exclusions are the cases under which you cannot raise a claim for a specific condition that is excluded from your policy. Even in this case, your health insurance claim letter for reimbursement would be denied if you raise a claim for a condition that is excluded in your plan. Thus, you must be careful in examining the exclusions of your health policy so that you can prevent such scenarios.PayBima's Khushi Ka Tohfa

Read More: How To Compare Affordable Health Insurance Plans Online In India?

To Conclude 

No one likes their claims getting rejected because if your claim is denied, you may not get the compensation money back and thus would have to use your savings to compensate for the loss. Even if you receive the claim amount later, the health insurance claim process still gets delayed and you receive the money very late.

However, the good thing is there are many steps that the insured can take to limit the probability of claims getting denied. The above mentioned points are some such instances under which claims are denied.  So, keeping in mind such points would help in making less mistakes and getting your claims approved.

Also read: What is Deductible in Health Insurance?

Found this post informational? Browse PayBima Blogs to read interesting posts related to Health Insurance, Car Insurance, Bike Insurance, Term Life Insurance and Investment section. You can visit PayBima to Buy Insurance Online.


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Sep 06, 2022
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PayBima Team
PayBima is an Indian insurance aggregator on a mission to make insurance simple for people. PayBima is the Digital arm of the already established and trusted Mahindra Insurance Brokers Ltd., a reputed name in the insurance broking industry with 17 years of experience. PayBima promises you the easy-to-access online platform to buy insurance policies, and also extend their unrelented assistance with all your policy related queries and services.

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