Common Issues with Health Insurance Claims

In recent times, there has been growing concern regarding the outright rejection of cashless claims by insurance companies whenever a patient is admitted to a hospital. Often, these claims are denied on various grounds. At times, the insurer contends that the hospitalisation was unnecessary, while in other instances, they claim the admission was solely for diagnostic tests rather than for genuine treatment purposes.

If these grounds are not available, insurance companies may send their agents to the hospital during a patient’s admission. These agents sometimes obtain written statements from patients, which are later used as grounds for rejecting the claim. For example, in one case, a patient who was already on medication and mentally unsound due to the effect of those medicines was visited by an agent. The agent got a handwritten declaration from the patient, stating he had suffered from asthma for more than ten years, based on complaints of cold and cough during hospitalisation. Subsequently, the insurance company rejected the claim, alleging non-disclosure of pre-existing asthma at the time of policy purchase, even though three years had already elapsed since the inception of the policy.

Such instances are not isolated. There are many cases where, after a cashless claim is denied and the patient is compelled to seek reimbursement, the insurance company may accept the same claim that was previously rejected, or sometimes reject the reimbursement claim on similar grounds.

Steps to Ensure Successful Health Insurance Claims

1. Disclosure of Pre-existing Conditions

To improve the chances of claim approval, it is vital for policyholders to disclose all pre-existing diseases and conditions at the time of purchasing the health insurance policy. Policies typically have a waiting period for pre-existing conditions, and claims related to such conditions are only honoured if the waiting period has passed and the condition was declared in the proposal form.

2. Submitting a Reimbursement Claim

When filing a reimbursement claim, it is important to submit all necessary documents as required by the insurance company. If the claim is rejected even after providing all requested documentation, policyholders can escalate the matter by visiting bhimabharosa.com to access the grievance redressal cell’s email ID and submit their complaint.

If the grievance redressal cell also rejects the claim, the next step is to escalate the complaint at bimabharosa.irdai.gov.in.

In most cases, following these escalation steps results in the insurance company approving the claim, either partially or fully.

3. Escalation to the Insurance Ombudsman

If the claim is still not approved, the next recourse is to approach the Insurance Ombudsman. This can be done through the online portal at www.cioins.co.in. The Insurance Ombudsman, appointed by the Insurance Regulatory and Development Authority of India (IRDAI), will hear the case and may either pass an award in favour of the claimant, reject the claim, or recommend mediation for settlement through mutual negotiation between the claimant and the insurance company.

Additionally, If a policyholder believes they have been defrauded by an insurance company—whether due to claim rejection, partial approval, or significant delays despite following the escalation process—they can file a complaint with the consumer forum. The appropriate forum is determined by the premium amount paid for the policy at the time of hospitalisation; in most cases, where premiums are modest, complaints are filed before the district consumer forum.

To file a consumer complaint, the individual can use the e-jagriti.gov.in portal for online filing and must appear physically at the forum to pursue the case.