Reason why your cashless Health Insurance claim could be denied

Health Insurance is no longer considered a luxury;it is a necessity these days. There are several reasons, like the ever-increasing healthcare costs and having a financial backup in case of medical emergencies, that make having a proper cashless health insurance in place imperative in good financial strategies. According to a study,about 86% of the rural population and 82% of the urban population is still not covered under any health insurance. While there might be many reasons behind these startling numbers, one of the most common reasons is the belief that people have regardinghow it is very hard to get a health insurance claim approved, and that claim rejection is more of a norm than a rare occurring. This is absolutely a myth and needs to be debunked as soon as possible. While claims do get rejected at times, more often than not there are concrete reasons behind the rejection. Read on to know more about cashless health insurance, claims, and why they might get rejected.

When you are covered under a health insurance policy, there are two ways in which you can file a claim – cashless and reimbursement.But, before getting into the types of claims, one thing that begs for an explanation is – network hospitals.

Every insurance company has a list of hospitals with which they have a tie-up. This list can easily be accessed by the insured on the insurance provider’s website or on their policy documents. These hospitals are referred to as the insurance provider’s network hospitals. Whether a hospital falls on the list of network hospitals or not can make quite a difference in the claim process:

• Cashless Claims–
  Cashless claims mean that you can get treated at a reputed network hospital without having to foot the entire bill yourself. On being admitted, you are supposed to provide the hospital with your insurance details so they may put in a request for cashless treatment with your insurance company, with all the required documents. The company then verifies the case and either approves or rejects the application for cashless treatment.
• Reimbursement Claims-
  As the name suggests, this claim is about getting reimbursed for the money you spend on healthcare or medical treatment. Once the patient has been admitted, they undergo the treatment and pay the complete bill from their pocket. Then, after they are discharged, they submit all the relevant documents to the insurance company to claim reimbursement.This claim process is to be followed when you get admitted to a non-network hospital.

For Planned Treatments

• For availing a planned cashless medical treatment,you are required to inform the insurance company well in time. In many instances, that would be at least 4 days before the treatment.
• Submit a cashless claim request form via post, e-mail or fax.
• Contact the customer care of your provider in case of any doubt.
• The insurance provider will notify you and the concerned hospital regarding eligibility.
• At the time of admission, display your health insurance card and confirmation letter.
• The bills will be paid by the insurance provider, directly to the hospital.

For Emergency Treatment

• Contact customer care of your insurance company to get information about the nearest network hospital.
• Display your health insurance card to avail cashless hospitalization.
• The hospital will fill in the cashless claim request form and submit it with the provider.
• An Authorization Letter will be issued by the provider to the hospital, indicating the coverage.
• The medical bills will be paid by the provider to the hospital.
• In case of rejection, a letter will be sent to you, stating the reasons for denying a claim.

One of the main stipulations of being eligible to claim cashless treatment is that the patient must get admitted to a network hospital only. Each insurance company has tie-ups with a number of hospitals and healthcare centers, where the insured can receive cashless treatment. You can check online or get in touch with the insurer’s customer care to find out about the nearest network hospitals. However, if you get admitted to a non-network hospital, you will not be eligible for a cashless claim, but might be able to later submit a request for reimbursement.

Unless it is a medical emergency and it simply cannot be avoided, you should always opt for admission to a network hospital for an easy claim process.

Before the payment for the medical treatment is made to the health care provider, the insurance company spends some time in verifying a claim. If at any point they see misrepresentation of facts, the claim is outright rejected. Sometimes, the mistake might be a simple overlooking of facts, but that won’t really matter. That is why it is very important to ensure that the claim form is filled out with due diligence before it is submitted.

When you are submitting your application form, you should make sure that you declare your health conditions truthfully. Incorrect information about your pre-existing diseases or health status may not only lead to a rejection of your claim, but may also result in your policy being cancelled. This may even take place after 10 years of you having the policy, even though pre-existing diseases are covered after a shorter waiting period.

What is mentioned above is the basic process that is followed when putting in a cashless claim. The exact procedure might slightly vary with different insurance providers, or it may be exactly as mentioned above. It is up to you to be well-versed in the procedures regarding your cashless health insurance. Not following the proper claim procedure is another reason why your claim might be denied.

As soon as you get your insurance policy, make sure that you are well-versed with the claim procedure, so you can take the appropriate steps when the needarises.

There are some diseases or situations that are considered as exclusions in a particular health insurance policy. It is again, up to you to know about them. If you are admitted to the hospital for a condition that is listed in the exclusions, you won’t be able to file a claim for it with your insurance company.

Some of the permanent exclusions that are not covered under a health insurance policy are:

• Injuries of illnesses caused by war or similar perils
• Directly/indirectly contracting sexual diseases, or illnesses caused by HIV
• Treatments for altering pregnancy
• Fertility treatments
• Treatments by an unlicensed physician
• Obesity
• Self-inflicted injuries
• Dental or cosmetic treatments
• Congenital ailments
• Alternative treatments

Temporary exclusions refer to illnesses that are not covered under a health insurance policy for a stipulated time period,also known as waiting period, and if you claim medical treatment for a temporary exclusion illness, your claim will be denied.

Some of the treatments that are treated as temporary exclusions in health insurance are:

• Any health insurance claim for 30 days from the inception of the policy, except for accidental injuries
• Pre-existing diseases have a waiting period of 1 – 4 years (varies from company to company) of continuous health insurance coverage with the company
• Diseases like cataract or hernia are covered after a waiting period of about 2 years

There may be several reasons why a cashless claim might be denied, but your insurance company always lists out those reasons when they reject a claim. However, when you file a claim with the right knowledge and diligence at hand, there is no reason why your health insurance claim would be denied.