Health insurance: despite payment of the premium, your application may be rejected! Know the reasons and how to avoid refusals

To cover the high cost of health care – notably hospitalization costs in private hospitals – the purchase of health insurance has become a necessity, unless there is full life-long cover from of the employer. Indeed, there are uncertainties regarding the need for hospitalization and the cost of treatment, while the amount of the health insurance premium – to cover the uncertainties – is certain and therefore manageable.

Thus, the sole purpose of subscribing to a mutual insurance company is either to benefit from cashless hospitalization, or to be reimbursed for the sums paid during hospitalization.

Therefore, despite the regular payment of the insurance premium, if a claim is rejected by the insurer, the basic purpose of taking insurance will be defeated.

It is therefore important that you know the reasons why health insurance companies deny claims and how to avoid claim denials.

Reasons for rejecting cashless benefits

To qualify for cashless benefits, an insured person must –

Visit a network hospital: A network hospital is a hospital with which the insurance company has a link to provide cashless care to policyholders.

In the event that a person has to go to a hospital outside the network for a valid reason, he must first pay the bill and then get the amount reimbursed by the insurance company.

Intimate insurer before scheduled hospitalization: For planned hospitalization scheduled in advance for surgery or treatment, the insured must notify the insurance company prior to hospitalization and have the cashless limit sanctioned. The limit can be increased, if necessary during hospitalization.

Without prior notice, the insured may have to pay the bill first and be reimbursed later.

The causes of outright rejection

Technical reasons

A complaint can only be admissible if the conditions set are met. Claims submitted in violation of the terms and conditions may result in rejections for the following technical reasons:

Period of hospitalization: A complaint is only admissible in the event of more than 24 hours of hospitalization for the purpose of treatment. Hospitalization for diagnostic purposes is also not eligible.

Waiting time: A complaint is not admissible if the hospitalization takes place within the waiting period after the subscription of a contract. According to industry standards, the general waiting period is 6 months, while for some specific diseases – which are slow onset – the waiting period is longer.

Daycare procedure: For certain treatments such as cataract surgery, etc., where 24 hours of hospitalization is not required, the claim will only be accepted when the treatment is on the list of eligible daycare procedures and the waiting period for processing is complete.

Suppression of material facts

While refusals for technical reasons are specific to each case, a more serious reason is the suppression of material facts when applying for a health insurance policy.

Here are some of the reasons complaints may be rejected:

Pre-existing illnesses: An applicant should disclose all health conditions when completing the application form with utmost care, so that no material facts are intentionally suppressed. Purchasing a health insurance policy while hiding health issues — such as having abnormalities in blood sugar, blood pressure, or any other medical condition — may result in the rejection of claims related to pre-existing conditions or abnormalities .

In accordance with the moratorium clause, rejection due to pre-existing conditions is not permitted after 8 consecutive years from the issuance of a policy. However, if there is evidence of intentional suppression of material facts, claims may be rejected for fraud even after 8 years.

Subsequent detection of health conditions: If abnormalities in health conditions – such as abnormalities in blood sugar levels, blood pressure, etc. or the onset of any illness – are detected even after taking out the policy, the insured must disclose it to the insurance company immediately after detection or at the time of taking out. policy renewal. Otherwise, there may be investigations at the time claims are submitted, even leading to claims being dismissed.

Deletion of facts at the time of transfer of the policy: When transferring a health insurance contract from one insurer to another, the insured must disclose all health conditions and anomalies present on the date of transfer of the contract. The removal of any condition which arose while the policy was under the old insurer must also be disclosed to the new insurer even if the old insurer was not informed in due time. Any intentional violation may be treated as fraud, resulting in disallowance of future claims.

It is therefore preferable not to transfer a policy, once the age of the insured reaches more than 50 years.

How to avoid claim rejections

Technical reasons: To avoid refusals for technical reasons, make sure that all conditions are met at the time of hospitalization or day care request.

Removal of facts: To avoid rejection on more serious grounds of suppression of material facts, when completing the application form, make sure you understand the terminology and complete the form with the utmost care to ensure that no facts are wrong. is intentionally deleted.

Remember that the revelation of true facts may lead to the imposition of certain loadings on the premium, which would increase it a little, or to the imposition of certain exclusions leading to making claims related to pre-existing conditions inadmissible , or to the dismissal of the claim, but the claims would not be dismissed after paying premiums year after year.


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