7 Reasons Why Your Health Insurance Claim Can Be Denied

7 Reasons Why Your Health Insurance Claim Can Be Denied

Advancements in medicine over the past few years have been a turning point in how diseases are diagnosed and treated. However, they have also resulted in the cost of healthcare being at an all-time high, making this state-of-the-art healthcare difficult to access without enough money. 

Thankfully, we have medical insurance plans to mitigate this problem. Most plans cover a huge chunk of costs related to treatment, bills, prescription drugs, etc. But, if your claim has a mistake in it or has not been filed correctly, health insurance companies can reject it. 

Here are a few reasons why your medical insurance company can disqualify your claim and not cover your healthcare costs. Read on to learn how to avoid these common mistakes!

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Common Reasons For Insurance Claims Getting Rejected

1. Inaccurate Information 

If your medical claim contains incomplete, inaccurate, or misleading or misrepresented information, your claim can be rejected. Most companies require critical information about your medical history and personal details such as pre-existing conditions, employment status, nature of the injury/ health complication, age, income, current insurance plan, etc.

If any of this information is wrong or incomplete, medical insurance companies can reject your claim and clarify what was wrong with it. The good news is you can correct your claim and supplement it with the correct, factual information and evidence. 

2. Unwarranted Hospitalization or Treatment

If medical insurance companies deem that your condition did not require hospitalization or a specific treatment plan that you were on, then your claim can be denied. 

When this happens, you can disclose more details like doctor’s notes and recommendations about your injury or condition to make your case stronger. 

3. Exceeding Waiting Limit

After your health issue or injury, you have a stipulated amount of time to apply for your medical insurance depending on the company. 

This waiting period is generally 60-90 days from the date of discharge.

While it may be the last thing you want to deal with after you’ve suffered ill health, filing the claim within this period is important. If you exceed this timeframe and file your claim after it’s over or near its end, your claim will be disqualified. There isn’t much else you can do in this case. 

4. Exclusions In Policy

Every medical insurance plan comes with its set of terms, conditions, and exclusions. Exclusions consist of special circumstances such as certain diseases or cosmetic surgery, for example, for which insurance cannot be claimed. 

If your condition falls under an exclusion, then the company will reject your claim. In order to avoid this, read your policy documents carefully and take time to understand each exclusion outlined. 

5. Exceeding The Sum Insured

Each company and plan will state a clear amount or sum of money insured. Depending on the plan you have chosen for yourself or your family, you will have a yearly limit on the amount of insurance you can get.

If your accident or illness treatments require an amount beyond the sum insured, then your claim will be disqualified. This also applies if you’ve used up your yearly limit already and need to file another claim. 

6. Expired Policy 

If your medical insurance plan has expired, then you cannot file for a new claim to cover your costs. It’s thus important to constantly be updated with your insurance plan.

Make sure you renew your insurance when you know it’s about to expire. Most plans are usually valid for a year. You should keep an eye on your policy expiration date to avoid a claim rejection when you need it the most. 

Renewing your policy also has its upsides, like paying lesser premiums. 

7. Pre-Existing Health Conditions 

This is a tricky one. While it is certainly possible for you to get coverage for a health issue while having a pre-existing condition, companies are known to reject claims on this basis. 

The good news is that, according to the Department of Health and Human Services (HHS), under the Affordable Care Act, insurance companies can no longer deny claims because of pre-existing health conditions such as diabetes or asthma. They cannot limit benefits or refuse to cover treatment. 

However, the exception to this law are the “grandfathered” policies, or policies that were bought before 2010. These may be an individual policy you bought for yourself or for your family from an agent. 

Such plans can lose their “grandfathered” status if they make major changes that either increase consumer costs or reduce benefits. These plans must also be disclosed. 

Make sure you check whether your policy falls under this criteria so you can switch to a more beneficial plan. 


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How To Avoid Common Mistakes?

1. Read And Understand Your Insurance Plan

Always go through your medical insurance plan thoroughly before agreeing to sign any documents or paying the premiums. Understand each clause, term, and exclusion in the policy before choosing a plan. 

2. Choose The Right Plan For You And Your Family’s Needs

Being smart with your choice of insurance plan will help you in the long run. Some plans work better for families while some are better for individuals. 

If you have pre-existing health conditions, you might want to consider a plan that doesn’t have a long waiting period, even if that means paying a higher premium. 

3. Check And Compare Different Plans

Compare different health insurance plans online to see what you are getting and whether you can find better options elsewhere. 

4. Maintain A Record Of All Important Documents

Keeping all of your hospital records, files, reports, scans, and prescriptions in one safe place is extremely vital. Insurance companies sometimes need histories of previous illnesses and treatments for clarifications. 

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Understanding the common mistakes while filing a claim can help you prevent disqualification from your insurance company in times of need. Insurance is there to help us, and not add to our stress.

Do your research thoroughly and choose a policy that best meets your requirements. Read through your policy to gauge its terms and conditions correctly so there is no room for a rejection later.

In case you have any questions regarding a rejected insurance claim or need help during the process of filing a claim, feel free to contact us at Celesticare. 

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