Health insurance policyholders may not have their claims settled by insurance companies at all times. Sometimes the full claim is rejected while sometimes partial claims are settled. There could be different reasons for claims to be rejected by insurers. “Applications are rejected for various reasons. According to our observations over the past two years, claims are rejected for unwarranted hospitalization, i.e. the disease could have been treated on an outpatient basis,” says Satish Gidugu, CEO and Full-time Director of Medi Assist .
Lately, especially after the coronavirus outbreak, the claims experience for policyholders seems unsatisfactory. Gidugu shares with us the Covid-19 claim scenario – Since 2020, COVID claims have seen a big increase and we have also noticed that claims have been rejected because people have opted for hospitalization instead of opting for home treatment.
Health insurance policies come with fine print that policyholders often forget to read, a considerable number of home care claims have been rejected because some policies did not cover home care. Regarding COVID vaccination, claims were rejected because many policies did not include COVID vaccination coverage. COVID-positive patients who received treatment and isolation services in hotels had their claims denied as it was not covered by insurance policies. We also observed that hospital treatments carried out using antibody cocktails were rejected because they did not require hospitalization.
Kapil Mehta, co-founder of SecureNow also echoes similar reasons leading to the rejection of Covid-19 claims – The main reason for the rejection of claims, especially Covid claims, is that the insurer felt that hospitalization n was not justified. The second problem was the partial settlement of claims because hospital charges were higher than stipulated rates. The third reason continues to be pre-existing conditions.
“For a smooth claims settlement, the most important thing is to make sure that the hospital clearly indicates the need for hospitalization. Also buy a highly rated product with no room rental restrictions and with a waiting period of more than 2 or 3 years. Finally, work with intermediaries who understand the claims process and know how to respond to questions raised by insurers,” suggests Mehta.