Top 6 Reasons Why Health Insurance Claims Get Rejected
Good health insurance can give you peace of mind and save your family from financial catastrophes. But what if your claims get rejected by your insurer? How would you feel then?
Health insurance claims are often denied due to several reasons. If you do not know what to look out for, your chances of getting compensated by your insurance company are very slim.
You can increase your chances of getting compensated by learning about the most common reasons why health insurance claims get denied and how you can avoid these mistakes in the future.
To ensure that doesn’t happen, here are six reasons why your claims might get rejected:
1. Your plan has limits on certain medical treatments and diagnostics.
Not all healthcare plans cover all expenses incurred during a single hospitalisation or major medical procedure. If your medical plan states that you are only covered for each hospitalization up to a certain amount, then expenses on top of that limit have to be shouldered by you.
For example, you need to undergo a kidney transplant that costs $75,000 but your health plan can only cover $50,000. Since you have exceeded the cover limit for that kind of procedure, you need to pay the rest of $25,000 as out-of-pocket costs.
Bottom line: It pays to know your policy inside and out—or at least spend time researching what your policy does and doesn’t cover. The goal is simple: understand exactly how much it will cost you and double check your health plan benefits before getting treatment, so you aren’t surprised by high bills or rejected claims down the road.
2. You ignored the exclusions.
Different types of health insurance have different guidelines for what is and is not covered. The exclusion of your insurance policy refers to a condition that is not covered by the plan. This can be found in your policy documents, your benefits table and your insurer’s general terms and conditions.
If you have a basic health plan, things like prescriptions or cancer treatment might be completely not covered as well major disease treatments or specific types of accidents. Some of the most common exclusions in a health plan are pre-existing conditions, cosmetic surgeries, and injuries from any risky sports and activities like mountain climbing and paragliding.
These sections should be read carefully prior to filing an insurance claim so that you avoid any unpleasant surprises.
3. You did not declare an existing medical condition.
This is a serious offense that could incur sanctions from health insurance companies and may lead to cancellation of your policy. It is important to make sure you are telling your insurance company about all your past and present medical issues.
If you suppress information or leave something out that they may need to know about your medical history that violates the policy terms, then there is a good chance that your claim will be denied, and your policy is at risk of being cancelled. Insurer claims handlers conduct a thorough background check on a patient’s medical history before approving a claim.
Sometimes patients will be dishonest, or forgetful about certain things. The more truthful you are with your insurance company and give them all your details, there will be no mistakes on their end, especially if it is an expensive procedure.
4. You exceeded the time limit for claim submission.
Each health insurance company has a specific amount of time that patients have to file their claims.
If you were injured and underwent a medical procedure but failed to submit the claims for the expenses after 2 years, then chances are you will not be able to be reimbursed that bill as the grace period has lapsed already. That is why it is important to file for compensation as soon as possible following an accident or inform your insurer and provide them details of your condition right away.
The last thing you want is having to argue with your brokers or insurance agents and try to reason out that your claims are still valid and justifiable.
5. You used up your plan limit.
The annual limit refers to the maximum amount an insurance company is willing to pay in benefits for an individual during a particular policy year. For example, your yearly maximum coverage is $1,000,000. After you reach the annual limit, you must pay for all health care costs you incur for the rest of the year.
Many health insurance plans have an annual cap. Make sure you have the right information about the over-all plan limit before signing your policy contract.
6. Your policy lapsed.
If you let your policy lapse and suddenly need to be hospitalised, you won’t be able to file a claim. Insurers and claims handlers will always check if your policy is active or not at the time of your accident, injuries, or medical procedure.
Be diligent and know your plan cover period and always be aware of your policy renewal schedule.
Understand your health insurance coverage carefully
Having an insurance claim denied is one of the worst things you can possibly experience. If you are not careful, it could set off a chain reaction that could result in you losing your coverage or incurring more costs down the road.
Stay vigilant when it comes to taking advantage of your benefits—it is easier to get on top of things at every stage of treatment. While medical bills can be confusing, it is still important to submit your claim. After you do, make sure to follow up on whether or not your claim was accepted.
If it gets rejected for one of these seven reasons, you can resubmit with an appeal. The more claims you get used to submitting, the easier it will be to identify mistakes and avoid them in future claims.
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Since 2008, A+ International Healthcare has been providing best-in-class medical health plans around the world. To know more about our products and services, visit http://www.aplusii.com, or follow us on LinkedIn, Facebook, Twitter, and Instagram for more updates.
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