Health insurance claim rejected — how to read it and what to check

Pre-existing disease, and the date everything turns on

Policies exclude conditions that existed before cover began, for a stated number of months of continuous coverage. Insurers may rely on a line in the discharge summary, such as "known case of diabetes for six years".

The questions are the same each time: when was it first diagnosed, or first the subject of a doctor's advice or treatment, and what does the policy count as the start of your cover? If you have held cover continuously across renewals, the clock may have started earlier than the current policy's date.

Waiting periods are not one period

A health policy can have several, and they are easy to confuse: an initial period after inception covering illness generally, longer ones for named conditions and procedures, and one for pre-existing disease. A specific waiting period can be as long as the pre-existing disease period, and where a condition falls under both, one insurer's wording applies the longer one; check yours.

Read which list your treatment falls in, and check whether the treatment followed an accident: by definition, specific waiting periods do not apply to treatment due to an accident, and IRDAI's standard format for the Customer Information Sheet says the initial waiting period does not apply to accidents either.

Deductions that are not a rejection

Not every shortfall is a refusal. Room-rent limits, sub-limits on specific procedures, co-payment and non-medical consumables all reduce what is paid without the claim being rejected.

If the amount paid is less than you expected, ask for the settlement letter and computation sheet. When a claim is partly disallowed, the insurer must give full details with reference to the specific terms of your policy.

Room rent limit

A cap per day, which some policies set as a percentage of the sum insured. Exceeding it can scale down other charges in proportion; the policy must state any proportionate deduction.

Sub-limits

A cap on a specific procedure, such as cataract surgery, regardless of the sum insured.

Co-payment

A set percentage of each admissible claim that you bear. Some policies apply it to every claim and some only in stated cases, so check your schedule.

Non-medical items

Items the policy lists as not payable, such as some consumables. Policies set these out in the wording; one insurer's product lists them in an annexure.

Cashless refused is not the claim refused

A hospital's cashless request can be declined without the claim itself being decided. Check your policy's cashless clause: in one insurer's wording, a cashless denial still lets you pay, complete treatment and claim reimbursement. If you do, keep every original document, and ask the insurer for the reason in writing.

Read next

• Your insurance claim was rejected. Here's what to do next.What a rejection letter actually means, how to check the insurer's reason against your own policy, and the steps open to you in India — explained plainly.
• Cashless request refused at the hospital — what it meansA denied pre-authorisation is not the same as a rejected claim. What to do at the hospital desk, what to collect before you leave, and how to claim reimbursement afterwards.
• How to read a claim rejection letterA rejection letter has four parts that matter and a lot of formality around them. Here is what to find, in what order, and what each part decides about your next step.
• Claim rejected because of the waiting period — which waiting period applies to me?Initial, specific or PED waiting period? Tell which one the insurer used, check your policy's list, count continuous cover and use the accident exception.
• Claim rejected because I was in hospital less than 24 hours, or it 'could be done in OPD'Rejected for a stay under 24 hours or as OPD care? Check the day care list, the hospitalisation and hospital definitions, and the times in hospital records.
• Pre- and post-hospitalisation expenses not paid — how do I claim them?How pre- and post-hospitalisation cover works, why these bills get refused (window, condition, main claim), and how to claim them with the right papers.