Round 25% of medical health insurance claims are rejected as a result of the insured had pre-existing circumstances like diabetes or hypertension, which weren’t disclosed on the time of buy. One other 25% of claims rejections are as a result of policyholders have been unaware of the phrases of canopy and claimed for OPD(outpatient division) or different therapy excluded underneath the coverage.A big chunk of claims (16%) are rejected as a result of the claimant didn’t revert to queries.
PolicyBazaar, which has an insurance coverage broking licence, analysed the information on two lakh medical health insurance claims between April to September 2023, of which 30,000 have been rejected.
From the insured’s perspective, the worst injury to their financials is attributable to claims rejected for non-disclosure. Whereas an equal variety of claims are turned down for being exterior the scope of the coverage, these are low-value claims, with the occasional declare being turned down for experimental procedures.
“Whereas rejections as a result of therapy being exterior the scope of the coverage are quite a few, they’re normally for low-value bills. The insured file many claims out of ignorance. We’ve seen OPD claims and claims for spectacles, that are, in fact, not coated,” stated Amit Chhabra, chief enterprise officer – medical health insurance, PolicyBazaar.
“Claims are typically rejected as a result of non-disclosure of fabric information. Whereas distributors might typically overlook or fail to make sure disclosure, the insured, as a celebration to the contract, bears accountability. It’s essential for insurance coverage consumers to not gloss over the proposal type, because the insurer might reject claims even when the non-disclosure is unrelated to the ailment,” stated Segar Sampathkumar, director of well being on the Common Insurance coverage Council, which represents the trade.
In keeping with Chhabra, most rejections are because of a lack of knowledge of the coverage. “Non-disclosure impacts even these claims which might be unrelated to the pre-existing situation. The largest giveaway is the preliminary report that the physician prepares on admission. Throughout admission, the insured has no selection however to declare all current circumstances because the course of therapy relies on it,” stated Chhabra. Insurance coverage legal guidelines mandate that the insured disclose all information which might be materials to the insurer’s determination to just accept the proposal. So, even when non-disclosure shouldn’t be materials to the reason for hospitalisation, the insured can reject the declare.
