Covid-19: A look at reasons why your health claim may get rejected

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Insurance companies are grappling with a steep rise in claim numbers due to the high number of Covid-19 cases in the country, While many cases get settled, a large number of cases also get rejected by insurers. According to General Insurance Council (GIC) data, insurers have received 15.32 lakh Covid claims until May 20, 2021 amounting to Rs 23,715 crore. Of this, 12.59 lakh claims worth Rs 12,133 crore have been settled.

Here are some common reasons for insurance claims getting rejected:

Documentation issue

Insurers have time and again complaint that due to pressure on their existing infrastructure system many hospitals are not able to share details about the patients. This at times is not sufficient as it gets difficult for insurers to approve the claim just based on the positive report. Insurers say that the severity of the case gets difficult to gauge just by looking at the Covid testing report.

Homecare

Considering that the number of patients is far higher than the effective number of hospital beds, many people are forced to get treated at home. Having said that, the onus is on the insured that it was not possible to treat in the hospital. The insurance company will reimburse you for home treatment only when there were no hospital beds available in your area. Check with your insurer before going for home treatment so that they are aware and let you know of the required documents to be submitted for the same. Importantly, many times claims get rejected if the insurance company is not informed about the domiciliary treatment. hence, before taking the home treatment always inform your insurer.

Mild cases

In case of mild covid symptoms that can be treated with oral tablets without any active monitoring then the hospitalisation might not get covered under health insurance. It is equally important to understand here that a hospital bed may be denied for someone with a serious condition if the mild patient has already occupied it.

Waiting Period

A new policy comes with the clause of the waiting period. This means that the coverage doesn’t start immediately but coverage begins after the lag of 15-30 days. For example, Covid-specific policies come with a waiting period of 15 days. On the other hand, basic comprehensive policies come with a waiting period of 30 days. Similarly, there is a waiting period of 2-4 years for pre-existing illnesses, which needs to be disclosed at the time of buying the policy. If any pre-existing condition is not disclosed at the time of buying the policy then it can lead to a rejection of the claim.

While taking the treatment make sure documents are in place and proper procedure is in place for speedy settlement of claims.