Group Health Insurance Claim Rejected? Here are 8 Tips to Ensure a Successful Claims Process

  • postauthorOnsurity Editorial
  • postdateJuly 26, 2023
  • postreadtime4 min read
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The purpose of a group health insurance policy is to offer you financial protection in times of a medical emergency. However, rejection at the time of claim can come across as a shocker to you, defeating the whole purpose of having an employer provided group health cover. While most of the claims are rejected on legitimate grounds, you can certainly take some precautionary measures from your end to ensure a successful claim and hassle-free settlement.  

Here are tips to avoid a group health insurance claims rejection 

Don’t give out false information: One of the most common reasons for claim rejection is the false information submitted by the insured. It is necessary that you be transparent with the insurer, providing accurate details related to your age, lifestyle habits, medical condition, etc. Providing misleading information can prove to be difficult for you at the time of claim. 

Non-disclosure of pre-existing medical conditions: When filling out the GHI form, it is necessary you disclose the correct information about the medical condition you may be suffering from. Even if you have diabetes, cholesterol, high blood pressure, cardiovascular problem, any surgery done in the past, etc. it is necessary you inform the insurer. Any pre-existing medical condition or any illness associated with it is covered only after a waiting period of 3-4 years. 

Know about the Waiting period: Most group health insurance policies offer coverage for pre existing diseases or specific diseases only after a waiting period of 2-4 years. Claiming for coverage during the waiting period can lead to claim. Hence, it is important to be aware of the clauses to avoid claim rejection in the future. 

Exclusions: Insurance companies mention a list of conditions for which they will never offer you any coverage. Generally, under a group health policy, conditions such as hospitalization due to suicide, alcohol consumption, etc. are not covered. 

Inform the insurer on time: In case of planned hospitalization, it is important that you inform the insurer at least 48 hours prior to  hospitalization.  In case of emergency hospitalization, it is necessary to inform the insurer within 24 hours. Not informing the insurer on time can lead to delays in the claim process and even rejection in certain cases. 

Check on the form filled by the employer: Your employer is the policyholder in case of group health insurance policy. At the time of policy enrolment, you should check whether the policy details are filled accurately or not. Ask if each of the employees can enroll separately or are included directly in the master policy. 

Expired policy: Check on the expiry date of your group health policy. Claiming for coverage during the expiry period can lead to claim rejection.  

Submission of wrong documents: In case of submission of wrong documents such as medical bills, discharge summary, etc. in case of reimbursement claim, the insurer is likely to reject your claim. 

 Tips for filing a group health insurance claims

  • Keep a check on the policy expiry date 
  • Note down the terms and conditions of the policy. Check for the exclusions, co-pay, etc. 
  • Ensure your company name, your name, date of birth, etc. are correctly mentioned. 
  • Make sure you file the claim within 24 hours of hospitalization 
  • Collect all the required documents such as medical bills, invoice, medical reports, etc. at the time of hospitalization 
  • Before filing the claim, check if all the documents are in place  

What to do in case of claim rejection?

The first step to follow in the case of claim rejection is to understand why the claim was rejected. Speak to the insurer or the TPA to know if there were any errors in the claim form or if a specific condition that you are looking to avail coverage for is not covered. If the claim was made during the waiting period, then the chances are high of rejection altogether. 

Reach out to the insurer or the TPA: In case you think that your claim rejection was not fair then you can reach out to the insurance company on email or call.  

Gather all the documents and relevant proofs: Gather all the relevant documents to reinstate the claim. Important documents required at the time of claim are: medical reports, policy copy, claim form, medical bills, doctor’s prescription, etc. 

 Approach the nearest ombudsman office if needed: In case you are unhappy with the decision of the insurer, then you can approach the nearest ombudsman office which will act as a mediator and arrive at a decision regarding your appeal against the insurance company. 

 File a case at the consumer court: As a last resort in case of rejection of claim, you can file a case at the consumer court. However, keep in mind that when doing this, you will need legal help which will probably cost you more than your claim amount. Plus, this would be very time-consuming. 

 It can be very stressful when your group health insurance claim gets rejected. Hence, it is always better to buy group health cover from a reliable company which can not only assist you at the time of hospitalization, but also at the time of claims. 

At Onsurity, we offer you healthcare membership that comes inclusive of health insurance cover, doctor tele-consultation, discount on pharmacy and diagnostics. Good Doctors Team at Onsurity is our dedicated claims concierge and ensures hassle-free, saree-free settlement of claims.

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