A Complete Guide to Health Insurance Claims: Filing Process & Documents

Life is unpredictable, and it comes with a custom-made clock, tick-tocking the minutes and seconds until things take a turn for the worse. The minus point of this ever-present clock is that it is invisible, and no one can hear the countdown. ⏰

That's right. I am talking about our health and its ups and downs due to major or minor accidents and diseases.

In that scenario, after roti, kapda and makaan, the next most important thing every individual must have is health insurance. Some insurance companies cover the maximum number of hospitals nationwide, whereas some provide better pre and post-hospitalisation coverage.

Getting a foolproof insurance policy is the best way to protect yourself and your loved ones from unexpected and unwanted accidents.

But, there are times when a policyholder diligently pays off the premium amount of an insurance policy, but still, their insurance claim gets rejected by the company. So, what to do when your only protective shield gets a hole in it?

In this article, your query in the matter will be solved. Additionally, as a bonus, I will provide you with a checklist of things to cross-check while choosing a health insurance policy.  

Now…

First Things First,

While you are choosing the health insurance policy, take a breather and seriously ask yourself: “Is this policy really the right one?”

To get the perfect answer, think of what kind of things are your priorities.

Suppose your family has any genetic diseases; does the policy cover them? Or what about the hospitals of your choice? Are they covered under the policy you have chosen? These things may take a bit of your busy schedule, but don't skip them.

Then, before you go through filing for a health insurance policy, make sure to ask yourself a bunch of different questions. Some of those are:

• Are the documents needed for the insurance claim filed appropriately?
• Is the data provided from your end foolproof and accurate?
• Have you submitted all the documents, photocopy or original, as mentioned, while filing your claim?
• Have you prepared a plan to renew the insurance policy without fail, and do you have further plans to avoid it if you fail to do so?

Congratulations! Now that you have cross-checked these queries from your end, your chances of an insurance claim rejection are reduced to almost 60%.

Wondering which health insurance to take and how much coverage you should opt for? Don't worry and read this article on "How Much Health Insurance Should You Take?" for a detailed explanation.

What to do When an Insurance Claim Gets Rejected?

Even if you follow all the rules, your insurance claim can still be rejected. This can be a stressful time, but don't panic! There is a step-by-step process you can follow to get the claim you deserve.
Here is what you can do in that scenario. Just make sure to follow them one by one without skipping any step.

1. Know the Reason & then File an Appeal

First and foremost, you must review the rejection document provided by the concerned health insurance firm. Policyholders receive a detailed record from their insurance company describing the reason behind the rejection of the claim. Once you know the reason, you can start to address it.

The bright light in this is that the insurance company is bound to provide the next possible step for the policyholder to get their claim accepted.

So, it's important that the holder first understand why the claim didn't pass through and see how to change it. There could be any missing documents or wrongful information to follow up on.

If you find the reason for the claim's rejection unfair, then you can file an appeal to your insurer. Be sure to include all relevant documentation and a detailed explanation of why you believe your claim should be approved.

If you still believe the outcome to be unfavourable, go to an Ombudsman.

2. Approach the Ombudsman from the Grievance Redressal Cell

An Ombudsman is an official responsible for responding to citizens’ appeals on the government’s improper activities. As per the Insurance Act 1938, insurance companies provide an Ombudsman for resolving policyholder’s grievances related to claim settlement, the difference in premium charges, violation of policy terms, etc..

So, an Ombudsman is like a third neutral party who is there to resolve the misgivings of the complainant and insurer. You can think of him as "The Godfather" from the 1972 crime film- he is there to “give justice”.

An Ombudsman is duty-bound to be fair and find a way to give unbiased opinions to resolve the issues.

The Consumer Affairs Department of the Insurance Regulatory and Development Authority (IRDAI) has a Grievance Redressal Cell. It is an inexpensive and simple method to raise a grievance to the official authorities. All you need to do is either call the Toll Free Number 155255 or 1800 4254 732 or send an email to the official email address complaints@irdai.gov.in. The Ombudsman assigned to your complaint will then help you resolve the matter.

Just remember to first file an appeal to the insurance company and then approach an Ombudsman. This way, you will save your time and resources.

Are you wondering what happens when the expert in the field, the Ombudsman, is unable to solve your query? Well, don’t worry! When all doors of justice are closed, one is always at your disposal. ⚖️

3. A Civil/Consumer Court

Policyholders can file a legal complaint against their insurer after exhausting all the options discussed earlier by visiting either a Civil or a Consumer Court. Many people have the bias that going to a court could be economically taxing. Though it is true most of the time, this theory does not apply to a Consumer Court.

Consumer Courts are bound to listen to every complainant and give fast-track judgments with fewer formalities. Hence, the complainant will save time & money and need not fuss with too many documentation issues while visiting a Consumer Court.

The Bottom Line

Though you can file a legal lawsuit against your insurance company, try to keep this as a last resort. Make sure to go through the options mentioned above first accordingly. If, after all this, you are not satisfied with the outcome, you have the Indian courts at your disposal.

This will give the holder credibility of following the right channel and increase your chances of success. Now that all your doubts are cleared up, what are you waiting for?

Get that health insurance coverage right now and surround yourself with a safety blanket ASAP.

Also Read:

• Why Does Every Investor Need Health Insurance?
• How Health Insurance Can Help You Save on Medical Expenses
• Health Insurance Plans for Family: Is Your Family Safe?