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Appealing a Health Insurance Claim Denial

By Prabhat Singh - May 2,2022
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Health insurance is one of the crucial financial investments that safeguard your pocket during any medical emergency. It helps you get rid of all the financial burdens you can experience during the hospitalisation of yourself or any of your family members. 

Almost all the insurance companies provide you with a cashless card, which allows you to pay the bills at the network hospitals directly through it. However, if you get admitted to a non-network hospital, you can file a claim for the reimbursement of all the medical expenses, and the insurer will settle the claim. Therefore, when you buy health insurance, one of the crucial factors is Claim Settlement Ratio. 

The number of cases settled against the number of claims filed in one calendar year is called Claim Settlement Ratio. The higher the ratio, the higher the chances of your claim getting settled. However, in some cases, your claim gets denied by the insurer based on reasons like policy lapsed or incorrect details given, or the ailment treatment is not covered etc. 

It is a little unfortunate if your claim gets denied, but it is not that if your claim gets cancelled on the first attempt, you will not get any reimbursement; you can always appeal for the denied claim. 

Also Read: How Much Health Insurance Do You Actually Need?

Here is what you should do once your claim gets denied: 

Find Out the Reason for Denial

The first thing is to read the denial letter sent to you and try to find out the exact reason for the denial. It could be anything like the incorrect information provided, the policy lapsed, etc. 

Review Your Insurance Policy

Once you know the reason for the denial, review your policy. See if your policy is still valid or whether your policy covers the treatment for which you filed the claim or not. In case your policy has not expired, and it covers the treatment, you are within your right to file an appeal for the denial. 

Find Out the Process of Filing a Claim Denial

After reviewing your policy, try to find out the actual process of filing the claim denial. You can call the helpline number of the insurer or can visit their branch office directly and inquire. Identifying the process earlier will help you structure the whole appeal process making it seamless. 

Follow the Process to File the Appeal

Once you have identified the process, go on and file an appeal for the denial. Follow the procedure set by the insurer and try to stick to it. Any discrepancies here will allow the insurer to deny your claim again. 

Transparent Communication

Ensure timely and accurate communication with your insurer, doctors and insurance agent via mail or post. It will ensure you have a paper trail and a complete track of the case until it gets settled. 

Do Not Forget to Follow Up

After you file the denial, make sure to follow up about the proceedings of the filed appeal with the insurer/insurance agent via mail or phone.

Health Insurance is essential, and so does appealing for the claim denial. You can always appeal for it, and every time the insurers will hear it. However, it is recommended that you understand the reason in the first instance and not repeat or make some new errors while filing the claim again.

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