While it may be easy to apply for a health insurance policy to manage your expenses related to health issues, it is definitely disheartening and stressful to face claim rejection for the same.
However, instead of worrying, you can correct your mistakes and reapply for reimbursement of your medical expenses. Here is a detailed outline of how you can appeal for a denied health insurance claim as a policyholder.
Find Out the Reason for Claim Denial
The following are a few major issues why your claim can be denied by the claims team, giving you an option to appeal for a denied insurance claim.
- If you raise a claim for a policy that has expired.
- If you raise a claim for an issue that the policy does not cover. For example, you cannot expect the benefits of a critical illness insurance plan by investing in a regular health policy.
- You have not provided supporting documents for the claim.
- Crucial details in the claim application are missing.
- You have raised a claim for an individual who is not included in the insurance policy’s purview.
Ways to Appeal Denied Health Insurance Claim
The insurer must inform you of the reason for the claim denial and the procedure to appeal their decision. Here are two ways in which you can appeal:
- Internal Appeal – This way to appeal medical insurance claim denial includes asking your insurer to make a complete and fair review of their decision.
- External Review – You can alternatively appeal for review from an independent third party, which is acknowledged as an external review.
Either Opt for Rectification or Reapplication
Once you know the reason for your claim being denied, you can make all necessary changes and apply again for a health policy claim. In case you have queries related to your claim rejection, you should preferably contact your insurer’s representatives for clarity.
Approach the Ombudsman
While appealing your insurance denial, you can reach out to the Insurance Ombudsman for help. The Insurance Act (1938) created the appointment of an Ombudsman to help policyholders settle their complaints.
The decision of the Ombudsman is impartial. Therefore, you must ensure that your medical bills and policy-related documents are in order for the Ombudsman to make a fair decision.
Re Approach with an Appeal Letter
To appeal your health insurance denial, you can also communicate with the insurer’s grievance redressal officers to obtain the necessary information. Instead of communicating via telephone, you are advised to send them either an email or a letter.
This letter should include details about your policy and coverage, as well as the reason for choosing this policy (your health issue). Attach necessary documents like medical bills and prescriptions.
Wait for Reply to your Appeal for Health Insurance Claim
Once you have sent the letter, wait for a response from the insurer’s end. It may take some time for the insurance company to finalise their decision, as they have to check and review the facts.
Conclusion
The primary reason for investing in a health policy is to avail oneself of financial help in times of medical emergencies or treatments. If, for any reason, your insurance claim gets denied, you can rectify it and appeal for the denied health insurance claim to receive financial reimbursement.
