Employers offer group health insurance to help their employees take care of their health and hospitalisation needs. However, in some instances, a claim can get rejected and you’re left feeling frustrated. Knowing why claims get denied can help you avoid common pitfalls and ensure smoother approvals next time. Let’s understand the reasons for claim rejection and offer practical ways to make sure your next claim does not get turned away.
Understanding the policy coverage
Before you file a claim, it’s crucial to know what’s covered.
Why it matters:
- Many people assume all illnesses and treatments are covered, but that’s not always true.
- Group health insurancetypically includes pre-defined conditions, treatments and hospital networks.
Example:
If your plan doesn’t cover cosmetic surgery or a specific kind of therapy, and you file for it, the claim will be rejected.
How to avoid this:
- Read the policy document carefully.
- Ask your HR or the insurer about unclear terms.
- Keep a checklist of inclusions and exclusions.
Pre-existing diseases not declared
If you don’t declare existing conditions when signing up and try to claim for them, the insurer may see it as a concealment. That counts as a breach of terms.
Always be honest about your health history. It’s better to declare than face a rejection.
Not following claim procedures properly
Claim processes may seem like just paperwork, but it is important to follow the set standard.
Why does it happen:
- Submitting incomplete documents
- Missing the deadline for filing
- Skipping pre-authorisation for planned treatments
How to avoid this:
- For planned hospitalisation, always inform your insurer or third-party administrator (TPA) in advance.
- Keep a copy of all documents submitted.
- File claims within the specified timeframe (usually 30 days post-discharge for reimbursement).
Treatment not medically necessary
Sometimes, insurers reject claims if the treatment isn’t considered necessary by medical standards.
Why does it happen?
- The insurer may believe the illness could be treated with outpatient department (OPD) care.
- Hospitalisation might be seen as excessive.
How to avoid this:
- Ask your doctor to mention the medical necessity on all reports.
- Provide complete documentation, including prescriptions and diagnostic reports.
Exceeding the sum insured limit
Group insurance policies come with a sum insured cap per person or family.
Problem:
- If your hospital bill exceeds this amount, you’ll be reimbursed only up to the insured sum.
How to avoid this:
- Always track your usage during the policy year.
- Some companies offer top-up options – ask your employer if this is available.
Policy lapse or inactive status
Even if it’s a group policy, there are situations when it might become inactive.
Why does it happen:
- If you’ve left the job
- If your employer didn’t renew the plan on time
How to avoid this:
- Confirm your coverage status before seeking treatment.
- If you’re leaving a company, ask if you can port the policy to an individual plan.
Mismatch in submitted documents
Even small mistakes can lead to rejection.
Why does it happen:
- Spelling errors in the name or ID number
- Bank details do not match the insured person
How to avoid this:
- Double-check all documents before submission
- Use one standard ID across all reports and claims
Conclusion
Rejection of a health claim can be disappointing. But most of the time, it’s preventable. If you understand your group health insurance policy, follow the proper procedures and keep your documents in order, the process becomes much smoother. If you’re unsure about any term or clause in your group insurance policy, reach out to your HR or insurance advisor for clarity. Being proactive can save you from claim troubles later.