Why Would Health Insurance Deny a Claim?
Health insurance is meant to be your safety net during uncertain times. But imagine the shock when, after a medical emergency, your claim gets rejected! It’s frustrating, confusing, and financially stressful.
This blog is here to guide you through the common reasons why health insurance claims get denied, with real case-inspired scenarios. Plus, learn how ClaimNikalwao can help you recover your denied claim effectively.
Circumstances When Health Insurance Is Denied
1. Lapsed Policy
If your policy is not renewed on time or the premium hasn’t been paid, your coverage lapses. A lapsed policy is considered inactive, and any claims made during this period are automatically rejected.
Case Example: Mr. Rajiv from Mumbai forgot to renew his health insurance after the due date. When he was hospitalized two weeks later for dengue, the insurance company declined the claim due to policy lapse.
2. Incorrect Information
Wrong or mismatched details in the policy or claim form—such as name, age, hospital name, address, or disease name—can cause rejection. Insurance companies verify all data strictly before approving claims.
Case Example: Anita’s claim was denied because the hospital’s name mentioned in the form didn’t match the hospital registered in her policy’s network list.
3. Filing Claim During the Waiting Period
Many policies come with a waiting period for certain illnesses. If you file a claim within this period, it will be denied.
Case Example: Rohit underwent hernia surgery 10 days after buying his policy. His claim was rejected since the policy had a 30-day waiting period for planned surgeries.
4. Hiding Information About Pre-existing Diseases
If you haven’t disclosed pre-existing illnesses while purchasing the policy, and later file a claim related to that illness, it’s considered concealment of facts and can lead to denial.
Case Example: Pooja’s diabetes was not declared during policy purchase. Later, her hospitalization due to diabetic complications was not covered.
5. Delay in Filing the Claim
Insurers set deadlines (like 24 or 48 hours) to inform them about planned or emergency hospitalizations. Delays beyond this window can lead to claim rejection.
Case Example: Rahul submitted his claim 12 days after discharge without prior intimation. His insurer denied the claim citing late submission.
6. Insufficient Documentation
Missing bills, discharge summaries, or incorrect paperwork can delay or deny your claim. Documentation is the foundation of your claim’s approval.
Case Example: Seema’s claim for maternity expenses was denied because the hospital bill and discharge summary were not attached properly in the claim form.
7. Exhaustion of Sum Insured
If you’ve already used up your insurance coverage for the year, new claims won’t be entertained unless you have a top-up or restoration feature.
Case Example: Arjun’s family floater had ₹5 lakh coverage. After two previous claims, there wasn’t enough balance left for his third hospitalization, and the claim was rejected.
8. Out of Coverage Treatments
Every policy excludes some treatments—cosmetic surgery, dental procedures, infertility treatments, etc. Claims made for these will be rejected.
Case Example: Rina underwent cosmetic surgery to remove a scar. Her claim was denied as cosmetic procedures are not covered.
9. Pre-authorization Not Taken
For cashless treatments, pre-authorization from the insurer is mandatory. Failure to get this approval on time can lead to denial or conversion into a reimbursement claim (which can also be denied later).
Case Example: Naveen admitted his father for bypass surgery without pre-authorization. Later, the insurer denied the cashless request, turning it into a long reimbursement process.
How ClaimNikalwao Will Help You for Health Insurance Claim?
1. Study of Documentation and Claim
Our experts first review all your submitted documents and insurance policy details thoroughly.
2. Discuss the Situation with Insurance Company
In some cases, we directly communicate with the insurer to understand their reason for denial and the possible resolution path.
3. File Preparation of the Client
We prepare your claim file professionally—ensuring no documentation gaps, clear justifications, and error-free forms.
4. Sharing of Case with Insurance Company
Your revised or appeal case is submitted with all supporting materials and legal explanation if required.
5. Response Wait from Insurance Company
We actively follow up and keep you updated as we await a formal decision from the insurer.
6. Discussion with Client for Further Move
Based on the insurer’s response, we guide you with the next legal or consumer court step if the denial still stands unfairly.
Read More: Health Claim Reimbursement by ClaimNikalwao
Final Thoughts
Health insurance claim denials can happen to anyone—even if you’ve done everything right. But don’t let it go unresolved.
At ClaimNikalwao, we’ve helped hundreds of people win their rightful claims through careful investigation, strong representation, and practical follow-ups. Whether your claim was denied due to a technicality or misunderstanding, our team ensures that your voice is heard.