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How to Escalate If your health claims gets rejected?

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Methods to Get your Claims Paid

Getting your insurance claim is one of the most important services that your insurance provider must offer you. If in any case, your claim is rejected because of a wrong information inserted at the time of agreeing to the policy or a mistake from the part of the insurance agent then you as the insured have every right to escalate the problem to the insurance company and fight for your claims.

Why your health claims gets rejected?

You apply for claim in the hope that it will be processed soon and you will get your money, but to your dismay you may find the claim rejected. Here are some reasons as to why a claim gets rejected.

  • Incorrect or wrong information – Giving any faulty or wrong information in your policy can affect your claim to be rejected. Always review your agreement policy before signing to make sure you have included accurate and trusted information.
  • Your coverage – Always check your policy thoroughly and make sure what your insurance covers, if you are applying for something which is not included in the coverage then your claim will be rejected.

Recommened Read : Possible reasons for Health Insurance Claim rejection

Check your policy documents

Check your insurance policy and claim form, if the name and number is accurate as well as you applied for the coverage as listed in the policy along with all other details you entered in the agreement, reports, files, documents, certificates, consultation fees, bills, summary, receipts etc. If there is a single error, it can lead to your claim rejection hence contact your insurance provider to make the relevant changes if any.

Contacting the insurance company

Once you have reviewed your policy and made sure that there are no mistakes from your part, then you can formally write a complaint to the insurance company stating your grievance redressal for claim rejection or call and speak to their complaint handling representative.

File an appeal

If the insurance company does not heed your words and still refuses to pay the claim, you have every right to file an appeal with your insurer, who will be called for an internal review to submit their decision and supporting documents on the case.

Get independent assessment

Contact a third party who is a loss assessor or loss adjuster to look into the whole scenario where you and the insurance provider is involved. He will look into the situation unbiased and send a report to the insurance company which will be considered as evidence and also charge you a fee for the same.

Seek the help of Ombudsman

The financial ombudsman offers independent and free service, investigating the complaint you raised against the financial institution. They will hear both sides of the story, cross check the documents and come to a fair conclusion. If they find right on your side then the insurance company will be called to explain their action, apologise and pay compensation.

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Ann Maria Cleetus took her Masters degree in Journalism after her graduation in Communicative English. She is passionate in writing. Ann writes for online magazines, websites, blogs, press releases for clients, newspapers etc. Ann Maia Cleetus left Marcomm job to concentrate in Writing.

6 COMMENTS

  1. Getting the insurance money is one of the most painful tasks for a common man. Unaware about the exact reasons and given the faulty or misappropriate information by the insurance company, most of the claimants end up losing their money. The solutions provided above though helpful might further put a hole in the pockets of the customer who is already reeling under the pressure of heavy medical costs. Transparency from the insurance company and being judicious before signing up for the policy are the only comfortable way out as per the current scenario

  2. Hard earned money when not received at the right time, brings a lot of stress and tension. The article throws light on the rejected claims and also on the reimbursement of the money. Rejection can be due to some faulty methods from either of the ends but both need to be very careful while dealing with such issues. Neither the company nor the person should be negligent while accessing this. The only solution to this which seems to be possible is, transparency of policies between both. After all ,every problem has a solution!

  3. The above article is quite informative, but every policy comes with the pros and cons. Most of the time customer is not able to get his claim accepted. As per the scenario, fault may be from either side. One needs to be very careful at every step and get updates to his policy’s norms time to time to avoid any flaw in the whole process.

  4. Supposedly, there have been instances where a claim gets rejected and that’s the height of irritation and anger combined.But, if all the information is correct and the policy too covers the amount mentioned there are very little chances that the claim is not offered.It may harm the policy giver’s reputation and they definitely keep that in mind.Answers all about claims!

  5. Insurance companies can be so unfair when it comes to health claims…
    When you break your leg, apparently they claim that having a leg in the first place is a pre-existing risk and condition so they will not honour your insurance! Makes me laugh so hard sometimes, though these are real problems for people with chronic health conditions.
    My heart goes out to people who do not have this simple information. Once they get rejected, they do not realise they can escalate the issue and get some relief from it.

  6. Wow! This article was very detailed. Ann Maria really does look out for the reader to make sure they know all their options and have all the access necessary to get their claim take care of properly. Also, the article was broken up in a way which didn’t leave the reader bored.

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