In the event of a medical emergency, health insurance provides a buffer. It keeps our hard-earned cash out of the hospital. Insurance companies, on the other hand, reject tens of thousands of claims each year. Many rejections could be due to inadvertent reasons. Many claims of covid-19 have been denied by insurance companies. You can go to the insurance ombudsman if your claim is genuine and you believe the insurance company is denying it on bogus grounds. We’ll look at how you can use an ombudsman to assert your rights in this article.
While many people believe that rejection is due to the health insurer’s fault, others are wise enough to know that it is due to their own shortcomings.
You can find causes for claim rejection or methods to avoid claim rejection all over the Internet, but you’ve come to the right site if you’re seeking the next step following a health insurance claim rejection.
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What should you do first?
When a health insurance claim is denied, the insurance company notifies the covered individual in writing of the grounds for the denial. If you believe the reasons for the insurance company’s denial of your claim are incorrect, you must notify the insurance company in writing by registered mail as to why you believe the reasons for the insurance company’s rejection of your claim are not justified.
The next step is to:
After notifying the company, send a copy of your protest letter to the IRDAI email address firstname.lastname@example.org and the company’s Grievance Cell.
If despite your protest letter, the insurance company does not accept or notify your claim within a month, you must file a complaint with the Insurance Ombudsman in your area.
What is the best way to contact an insurance ombudsman?
The insured person can file a complaint with the Insurance Ombudsman by drafting an application and mailing it or emailing it to the Insurance Ombudsman.
Details: In this application, you must fill in the name of the insured, signature, insurance policy number, insurance claim number, and the amount of the claim.
After completing the application with the above information. Fill in the entire address, including the pin code, phone number, email address, insurance company name, and the address of the office where the policy is purchased.
You must include a copy of the hospital bill, doctor’s prescription, investigation report, and insurance company denial letter with your complaint.
You must provide the grounds for the insurance company’s claim rejection as well as the reasons why your claim is valid in the complaint application.
You should also be aware of the following:
The Insurance Ombudsman can be contacted in writing, in person, or by mail. The insured or the insured’s heir can file a complaint with the Insurance Ombudsman. A complaint to the Insurance Ombudsman is not possible while a claim case is pending in the consumer court. The Insurance Ombudsman does not impose a fee for filing a complaint.
Avoid Rejection of a Health Insurance Claim by Acting Proactively
Insist on getting a health check-up while purchasing a health insurance plan. If a medical test is not required by the policy (generally, individuals under the age of 46 are not required to go through any pre-policy health check-up in various cases), make sure that your current health status is revealed in your policy document, and don’t forget to keep an acknowledgment of the same.
It is recommended that you choose a cashless health plan because the insurance provider will need to approve the hospital ahead of time. It is a superior option because the insurance company pays the hospital directly and requires less documentation; also, the claim settlement process is quick and easy.
Furthermore, keep in mind that any health insurance company cannot deny a claim if you have been paying premiums for your health insurance plan for at least 8 years. The Insurance Regulatory and Development Authority of India has officially said this ( IRDAI). Keep in mind, however, that little honesty and detailed presentation of information from your end can go a long way toward reducing the likelihood of your health claim being dismissed.
Rejection of a health insurance claim can put you in a stressful situation.