Published on: 06/16/2025
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Health insurance is supposed to be a safety net and a lifeline when medical expenses hit hard. But what happens when that lifeline fails? The truth is, health insurance claim rejection is more common than most people realize.
Imagine being hospitalized, paying hefty bills, and then finding out your health insurance claim has been denied. Painful, right? To avoid such unpleasant surprises, you need to understand the top health insurance claim rejection reasons and how to prevent them.
In this blog, we break down the 12 most common reasons for rejected mediclaim requests and provide tips to avoid health insurance claim denial.
A rejected claim doesn’t just mean losing money it also brings stress during a time when you need support the most.
In India, many people still don’t fully understand how health insurance works. They buy a policy but skip reading the details. Because of this, claims often get rejected not due to fraud, but because of small mistakes or lack of awareness.
Knowing your policy well, like what’s covered, what’s not, and how long the waiting period is, can help you avoid problems later. Also, checking the claim settlement ratio of an insurance company tells you how often they actually pay claims. The higher the ratio, the better.
In short, the more you know about your mediclaim policy, the better protected you are when it truly matters.
Even if you have a health insurance policy, your claim can still get rejected. In most cases, it happens because of small mistakes or not fully understanding the policy. To help you avoid this, here are the most common reasons why health insurance claims are denied. Knowing these can save you a lot of stress during a medical emergency.
When applying for health insurance, insurers ask whether you have any pre-existing medical conditions such as diabetes, high blood pressure, asthma, or past surgeries. If you fail to disclose this whether intentionally or unintentionally it may be considered concealment of facts.
Even if your condition doesn’t seem serious to you at the time of application, insurers have strict underwriting policies. When a claim is raised later and the insurance provider uncovers undisclosed health issues, the claim is likely to be rejected outright.
This is one of the most common reasons for rejected medical cases in India. Since insurers often cross-verify your hospital reports, medical history, and consultation records, any mismatch can raise red flags and lead to claim denial.
Every mediclaim policy includes a waiting period clause. A general waiting period of 30 days applies from the day your policy begins, during which claims are not allowed except for accidental hospitalization.
Additionally, there are condition-specific waiting periods. For example:
If you raise a claim for a treatment that falls within this time frame, it will likely be denied. Many policyholders overlook this detail, assuming that coverage begins from day one, but that’s rarely the case.
One of the more frustrating reasons for claim rejection is a lapsed policy. If you fail to pay your premium within the due date (even if unintentionally), your policy becomes inactive. During this period, no insurance claim will be entertained, no matter how genuine the situation.
Insurers typically allow a grace period (around 15–30 days), but if a medical emergency occurs during the lapsed period or if you try to raise a claim after a lapse, the insurer has every right to reject it.
This is why policy renewal reminders must never be ignored. A lapsed policy nullifies the agreement and you essentially lose the entire benefit of your health insurance.
Every health insurance plan comes with a list of exclusions illnesses, treatments, or circumstances that the policy doesn’t cover.
Some common exclusions include cosmetic or plastic surgeries (unless necessary due to an accident), dental procedures, infertility treatments or IVF or alternative therapies like naturopathy (unless specified in your policy)
Raising a claim for any of these treatments, even if incurred in a hospital, will likely be rejected. Many policyholders mistakenly assume that all medical treatments are covered. But unless your mediclaim policy specifically includes them, the insurer is not liable to pay.
When filing a health insurance claim, the paperwork is critical. Your insurer requires a complete and accurate set of documents to process the claim. This usually includes:
Missing documents or submission of scanned/photocopied bills (when originals are required) can lead to delays or outright rejection. Also, if there are discrepancies between your submitted documents and the insurer’s requirements, the claim could be marked invalid.
Timely intimation is a crucial step in the health insurance claim process. Insurers expect you to inform them within a specific timeframe, usually 24 to 48 hours for emergency hospitalizations and up to 3–5 days for planned admissions.
Failure to notify the insurer within the stipulated time can be seen as non-compliance with the terms of your policy. This can lead to the claim being rejected, especially in cashless claims where prior authorization is mandatory.
This is particularly relevant in reimbursement cases. If the insurer is unaware of the hospitalization and the claim reaches them after treatment, they may consider the case ineligible.
If you’re expecting to avail a cashless facility, you must be treated at a network hospital, a hospital that has a tie-up with your insurer for direct billing. If you get hospitalized at a non-network hospital and still apply for cashless treatment, the claim will be denied.
While reimbursement may still be possible, the cashless claim process won’t be honored. This creates confusion for many first-time policyholders who aren’t aware of this requirement.
Always check the network hospital list of your insurer before proceeding with admission, especially in planned treatments.
Filing a health insurance claim isn’t just about submitting documents. There’s a specific process for each insurer:
If you miss a step or fill the form incorrectly, the claim may be rejected due to procedural lapses. This could include signing in the wrong place, sending incomplete forms, or failing to follow up.
Every insurer outlines their claim process clearly, but policyholders often don’t review these steps until it’s too late.
Every health insurance plan comes with a sum insured, which is the maximum amount you can claim in a year. If your treatment cost exceeds this amount, the insurer is not obligated to pay anything beyond the limit.
Additionally, most policies have sub-limits on:
If your bills go over these sub-limits, the insurer will approve the claim only up to the limit, and reject the rest. Many rejections are partial, where only a portion of the claim is approved and the rest is denied.
Insurers usually cover hospitalization and treatment costs that are medically necessary and prescribed by a certified doctor. If you undergo treatment without a valid prescription or opt for procedures that don’t require hospitalization (like general wellness check-ups or preventive care not covered) your health insurance claim might be denied.
Also, some people attempt to use their insurance for non-essential or over-the-counter treatments, assuming it will be covered. But unless prescribed, such costs are often rejected.
A surprising number of claims are rejected because of minor errors like spelling mistakes in the insured’s name, wrong policy number,incorrect gender or age on medical reports or using someone else’s insurance card or ID
While these may seem like clerical issues, they cast doubt on the validity of the claim. Insurers have strict identity verification processes, and any mismatch can result in rejection or request for re-submission delaying the settlement.
Always double-check all details before submitting a claim.
Insurance companies treat fraud very seriously. If you submit fake bills, exaggerate the treatment costs, or manipulate hospital records to extract higher benefits, your insurance claim will not only be rejected, you may be permanently blacklisted.
In some cases, the insurer may even pursue legal action against you for insurance fraud. Claiming for fabricated treatments, ghost admissions, or issuing forged receipts are serious offences
This is a major reason for health insurance claim rejection, and it damages the credibility of the entire insurance ecosystem.
A health insurance claim should be your safety net, not another battle to fight. Most rejected medical reasons are avoidable if you stay informed, act on time, and remain honest with your disclosures.
The key is to treat your health policy like a contract, not a formality. Read the fine print. Ask questions. Choose wisely.
In times of medical need, your focus should be on recovery not reimbursement. And with the right approach, you can ensure your insurance claim supports you when it matters most.
First, ask for the exact reason in writing. If it’s something correctable (like missing documents), you can resubmit. You can also escalate the issue to the IRDAI or insurance ombudsman if needed.
Yes, if the rejection was due to a documentation error or delay in submission, you can often reapply with proper documents and timelines.
Not directly. But repeated rejections due to fraud or non-disclosure can lead to blacklisting or denial of new policies.
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