Insurance Claim: Health insurance claim got rejected...take this action and recover every penny..
You bought a health insurance policy so that in difficult times, when a medical emergency arises, you do not have to worry about the cost of treatment. But imagine, when you are in the hospital and you come to know that the insurance company has rejected your cashless claim or post-treatment reimbursement claim. This can be a big shock for anyone.
But panicking or giving up in such a situation is not a solution. As a policyholder, you have many rights. If you feel that your claim has been wrongly rejected, you can get your rights by following a prescribed procedure. Let us understand this entire process step-by-step.
First of all, know why a claim gets rejected?
Before taking any action, it is important to understand why companies reject claims. Some common reasons are:
Pre-Existing Disease
If you did not disclose any pre-existing disease (such as diabetes or high blood pressure) while taking the policy, or the waiting period for that disease has not ended yet, then the claim may be rejected.
Policy Exclusions
Some treatments are not included in every policy (such as cosmetic surgery). If you have claimed something like this, it will be rejected.
Incomplete or incorrect information
Making a mistake while filling out the form or deliberately giving wrong information.
Late filing of the claim
Usually, the claim has to be filed within 7 to 15 days of discharge from the hospital. Delay can also lead to rejection of the claim.
Incomplete documents
Not submitting bills, doctor's report, or other necessary documents.
What to do if the claim is rejected?
Step 1: Calm down and read the rejection letter carefully
First of all, do not panic. The company will inform you in writing or by email, giving a reason for rejecting the claim. Read this 'rejection letter' very carefully. It will contain the reason why your claim has been rejected.
Step 2: Talk to the insurance company (First Level)
Sometimes the claim is rejected only due to a lack of some documents or a misunderstanding.
Call the company's customer care and tell them your policy number and the reason for the claim rejection.
If any document is missing, submit it immediately.
To put your point strongly, also write an email to the company, in which you explain why their decision is wrong.
Step 3: Write to the Grievance Redressal Officer (GRO) (Second Level)
If your problem is not resolved by the customer care, then the next step is to write to the company's Grievance Redressal Officer (GRO). Every insurance company has a GRO, whose job is to listen to the complaints of the customers. You will find the email ID and address of the GRO on the company's website or in your policy document. Write them a detailed email or letter, including your entire problem, policy number, claim details, and a copy of the rejection letter. The company has to resolve your complaint within 15 days.
Step 4: Insurance Ombudsman - Your biggest weapon
If the company does not resolve your complaint within 15-30 days or you are not satisfied with their response, then you can go to the Insurance Ombudsman.
Who is he?
The Insurance Ombudsman is an independent government body that resolves disputes between customers and insurance companies without any fee.
How to complain?
You can visit the Insurance Ombudsman's office in your city or complain online. You have to fill out a form and submit all the documents related to your complaint. You can go to the Ombudsman within one year of the company's final response. The decision of the Insurance Ombudsman is binding on the insurance company; that is, they have to accept that decision.
Role of IRDAI and Last Option
IRDAI: You can also register your complaint on the 'Bima Bharosa' portal of the insurance regulator IRDAI. IRDAI does not directly pass your claim, but it sends your complaint to the concerned company and asks for a response to it, which puts pressure on the company.
Consumer Court
If you are not happy with the decision of the Insurance Ombudsman, then the last resort is the Consumer Court. Here you can file a case against the company.
Disclaimer: This content has been sourced and edited from Zee Business. While we have made modifications for clarity and presentation, the original content belongs to its respective authors and website. We do not claim ownership of the content.
