10 Most Common Health Insurance Claim Rejection Reasons in India – Health insurance is a crucial financial safety net that protects you and your family from unexpected medical expenses. However, many policyholders face the frustrating experience of claim rejections, leaving them to bear hefty medical bills out of pocket.
Understanding why claims get denied can help you take preventive measures and ensure a smooth reimbursement process. In this blog post, we’ll explore the 10 most common reasons health insurance claims get rejected in India and provide actionable tips on how to avoid them.
1. Incorrect or Incomplete Information on Application
One of the most common and inadvertent reasons for health insurance claim rejection is due to incorrect information. Providing false, incomplete, or misleading information during the policy application process, such as hiding pre-existing diseases or providing incorrect age details, can lead to outright claim rejection.
How to Avoid It:
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Fill out your application truthfully and double-check all information.
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Disclose all pre-existing conditions, even if minor.
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Don’t let an agent fill the form without your verification.
- Always verify all the information provided in the form, against the original documents.
2. Non-Disclosure or Incorrect Disclosure of Pre-Existing Diseases
Why Health Insurance Claims Get Rejected:
Another common reason for health insurance claim rejection is due to pre-existing disease India. Insurance companies require policyholders to declare any pre-existing conditions (such as diabetes, hypertension, or heart disease) at the time of purchasing the policy. If you fail to disclose or misrepresent these conditions, the insurer may reject claims related to them later.
How to Avoid It:
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Be transparent while filling out the proposal form.
- Get a medical check-up done, if required.
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Provide accurate medical history, including past illnesses and treatments.
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If you’re unsure about a condition, consult your doctor before applying.
3. Waiting Period Clause Not Fulfilled
Most health insurance policies in India have a waiting period, typically 30 days for general illnesses and 2-4 years for pre-existing conditions. Health insurance waiting claim denial is another common health insurance claims rejection reasons in India.
How to Avoid It:
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Check your policy’s waiting period clauses before buying.
- Understand your policy’s waiting period clause.
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Avoid making claims for conditions within the waiting period unless it’s an accident (which is usually covered immediately).
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Opt for policies with shorter waiting periods if you have known health issues.
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Plan elective surgeries only after the waiting period is over.
4. Treatment Taken from a Non-Empaneled Hospital
Cashless claims are only applicable at network hospitals tied to your insurer. If you get treated at a non-empaneled hospital, your insurer may reject the cashless request, forcing you to pay upfront and file for reimbursement (which also has risks). Claim rejection due to non-network hospital India. Some policies cover only network hospitals or deny claims for non-recognized facilities, alternative therapies, or non-allopathic treatments.
How to Avoid It:
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Always check the insurer’s list of network hospitals before hospitalization.
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In emergencies, inform the insurer immediately for approval.
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If treated at a non-network hospital, keep all bills and documents for reimbursement claims.
5. Insufficient Documentation or Medical Records
If your claim lacks supporting medical documents, prescriptions, discharge summaries, or bills, it may be rejected. Missing or incorrect documents (discharge summary, bills, prescriptions, KYC) are a major reason for claim rejections. Documents required for health insurance claim India.
How to Avoid It:
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Keep all medical records, bills, and prescriptions organized.
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Submit signed claim forms with supporting documents.
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Follow up with the hospital for the correct paperwork.
6. Delay in Filing the Claim – How late submission result in Health Insurance Claim Rejection
Claims must be submitted within a specific timeline (e.g., 7–30 days for reimbursement) depending on the insurance policy. Delay may lead to automatic rejection. Most insurers require prior intimation (within 24-48 hours) for planned hospitalizations and immediate notification in emergencies. Delayed reporting can lead to health insurance claim rejection reason.
How to Avoid:
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Know the TAT (turnaround time) for both cashless and reimbursement claims.
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File all necessary paperwork on time.
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Notify the insurer as soon as hospitalization happens.
7. Policy Lapsed Due to Non-Payment of Premium
If you miss premium payments, your policy may lapse, leaving you without coverage. Any claims made during the lapsed period will be rejected. In some cases, if your policy has lapsed due to non-payment of premium, even by one day, your claim will be rejected.
How to Avoid It:
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Set up auto-debit or reminders for premium payments.
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Check the grace period (usually 15-30 days) to renew without penalties.
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If lapsed, reinstate the policy as soon as possible.
8. Claim for Non-Medical Expenses
Expenses like registration fees, service charges, toiletries, and food for attendants are usually not covered. Insurers may reject claims if they believe the treatment was not medically necessary (e.g., unnecessary diagnostic tests, prolonged hospitalization without cause).
How to Avoid It:
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Review the bill to separate reimbursable vs. non-reimbursable expenses.
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Understand what is termed as “consumables” and avoid including them in your claim.
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Ensure all treatments are doctor-recommended.
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Avoid unnecessary tests or extended hospital stays.
9. Multiple Claims or Fraud/Misrepresentation
If you have multiple policies or fail to coordinate between them properly (e.g., when merging or upgrading policies), claims may get delayed or denied. If the insurer suspects fraud (fake bills, exaggerated claims, or staged hospitalizations), they may reject the claim and even blacklist the policyholder.
How to Avoid It:
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Keep your insurer informed about any other policies you have.
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Use a single policy per hospitalization when possible.
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Never submit fake bills or documents.
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Avoid middlemen promising “guaranteed claims.”
10. Exclusions Mentioned in the Policy
Every policy has exclusions—conditions or treatments not covered (e.g., cosmetic surgery, dental treatments, alternative therapies). Claims for excluded treatments are automatically rejected.
How to Avoid It:
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Read the policy document carefully to understand exclusions.
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If needed, buy add-on covers for specific treatments.
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Consult your insurer before undergoing any expensive procedure.
Final Tips to Prevent Health Insurance Claim Rejection
✔ Buy the Right Policy – Compare policies and choose adequate coverage.
✔ Disclose All Medical History – Avoid hiding pre-existing conditions.
✔ Follow Policy Terms – Adhere to waiting periods, network hospitals, and claim procedures.
✔ Keep Documents Ready – Maintain organized medical records.
✔ Stay Informed – Regularly review policy updates and renew on time.
Conclusion
Health insurance claim rejections can be stressful, but most are avoidable with proper awareness and precautions. By understanding these 10 common rejection reasons and taking preventive steps, you can ensure a hassle-free claims process and maximize your health insurance benefits.
Did you ever face a claim rejection? Share your experience in the comments!
Disclaimer: This blog is for informational purposes only. Please verify policy details with your insurer before making decisions.
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