What To Do If Your Health Insurance Claim is Denied?

What To Do If Your Health Insurance Claim is Denied

One gets medical health insurance done if the person faces any medical emergency, and they cannot pay the wholesome amount at a particular time. The monthly premiums given to the insurance companies make it possible for people to get treatment during medical extengies without putting a hole in their pockets. Medical Health insurance policies have played an essential role in everybody’s life and are drastically increasing in recent years. One should never doubt the importance of medical health insurance. But when we are putting so much effort into getting insurance and depositing premiums every month, and the insurance companies reject your claim in the time of need, then what is the point of this process or this policy? So, here we will talk about what to do if your health insurance claim is denied.

Many times, insurance companies reject the claim of health insurance. This is mainly because we don’t pay attention to the minute details of the policy and not read the terms and conditions properly. And during the emergency, some insurance policymakers use these technicalities to back off from the coverage.

Thus, it is essential to understand the situation in which the health insurance claim is denied. And in case of rejection, what to do?


Why Do Health Insurance Claims face Rejection?

There are various circumstances in which the insurer has to face the rejection of the claim of the health insurance policy. These situations are as follows:-

  1. A particular disease or an ailment from which the policyholder is suffering is not a part of the claim of health insurance policy
  2. The filing of the claim is not proper
  3. The procedure is purposely done to get the claim. The patient did not require it.

These are the primary reasons why insurance companies reject the Health insurance policy claim. But still, these claims highly depend on the medical conditions and the paperwork put in by the patients.


What To Do If Your Health Insurance Claim is Denied?

Here are 5 things you can do if your health insurance claim is denied.


#1: Identify the reason for rejection.

The first and foremost step to deal with the Health Insurance Claim rejection is to understand why the rejection of the claim took place. There are many reasons the insurance companies deny the claims. Other than the reasons stated above, various other circumstances in which the insurance companies turn down the claims. They are:-

  1. Incomplete information regarding the insurance policy or the ailment
  2. Lack of Precertification or prior authorization
  3. Non-capture of tests and procedures
  4. Not complying to the time deadlines
  5. Co-pay and Deductible Clauses

The rejection of the claims happens in other situations as well. But if the insurer is not aware of the reason for the rejection, they cannot reclaim it, and the patient might have to pay for the treatment on their own.

Also read: Difference Between Critical Illness Insurance and Health Insurance

This makes it the top thing one should analyze in a situation of claim rejection.


#2: Collect the supportive documents

Many times, hospitals, doctors, and even the insurance companies may help the policyholders change the results of the claim.

Social workers play an essential role during this time. Many Social workers are also hired by the hospitals to help them in dealing with the denied claims. They also help them in obtaining the medicare facilities who qualify for the same. Generally, these social workers are a part of the charity department of the hospital. The social responsibility department of the hospital and the social workers act as proxies for the patients and help them in getting the claims. This is one of the hospitals’ best practices, which helps the patients at a substantial level. The social workers help identify the reason for the rejection and correct the mistake done by the patients.


#3: Apply and Reapply

The third thing you can do if your health insurance claim is denied is to apply and reapply. Once you can identify where your claim went wrong with the help of the social worker, you should apply for the claim again. Insurance companies try their best to not provide the claims to patients, as they try to keep the money to themselves. Still, if the classification of the claims is correct, they are legally obligated to cover the medical expenses.

Also read: Complete Guide to How Does Car Insurance Work?

With the digitization and the popularity of health insurance, the companies have started using automated software to identify that if the companies should deny or approve the claim. In case the claim faces rejection due to some inappropriate paperwork or due to the glitch in the system, the more you apply, the higher the chances of getting covered. Thus, one should keep on applying for at least 3-4 times.


#4: Keep records of everything

One of the best ways to make sure that your claim does not face any rejection is to record everything. Every paper that you are submitting to the company and every communication you receive from the company’s side is necessary to keep the record of the same. The digital paper trail is probably the best solution to this problem. In today’s world, any physical paper can be faked by the insurance company or by the patient to recover the money paid. But to manipulate the digital trail, it is still tricky.

Make sure to ask detailed questions about your case to your doctor or the insurance company so that the evidence and the communication are crystal clear for even the third party. This thing will help the patient as evidence of each, and everything is available.


#5: Become aware of the price of the treatment

Often, the insurance companies undervalue or overvalue the treatment costs so that they do not have to pay the whole amount they owe. Patients are sometimes unaware of the treatment costs they owe and insurance companies con them. Thus, it becomes necessary to understand the cost of the treatments you undergo. The insurance company often denies the claim pertaining to the value of the procedure. Hence, it becomes easy to negotiate with the companies if the consumer is aware of the treatment costs.



Denying the insurance claim is a widespread phenomenon in these times. Thus, the patient or the policyholder needs to be smart enough and educated to claim the coverage by fighting with the companies in or out of the court. So, there are various things you can do if your health insurance claim is denied. All you need to do is to work smartly.

We hope this article solved your queries and if you still have some, please mention them in the comments below.