Health insurance is a type of agreement (usually a contract) between you and an insurance company where you pay a regular fee (called a premium), and in return, the company helps cover your medical expenses when you get sick, injured, or need health care services. It can help pay for doctor visits, hospital stays, medicines, surgeries, and preventive care like vaccines and regular check-ups. Without health insurance, you would have to pay all your medical bills by yourself, which can be very expensive.

Key features of healthcare insurance

Premium is the amount you pay periodically- monthly, quarterly, or yearly—to keep your health insurance active.

1. Coverage refers to the range of medical services and expenses the insurance policy will pay for, such as doctor consultations, hospitalization, surgeries, prescription medicines, preventive health check-ups, maternity care, and sometimes even dental and vision care.

2. Deductible is a fixed amount you must pay out of your own pocket each year before your insurance begins to cover costs.

3. Additionally, health insurance may involve a copay or coinsurance, where you pay either a small fixed fee (like ₹200 for a doctor visit) or a percentage of the total medical bill (such as 20%).

4. Many insurance companies also have network hospitals where you can avail of cashless treatment, meaning the insurance company directly settles the bill with the hospital without you having to pay upfront.

Health insurance is important for several reasons. It helps reduce the financial burden by protecting you from sudden and high medical expenses, which can otherwise be overwhelming. It also provides access to better healthcare, allowing you to afford quality hospitals and treatments that might be too costly without insurance. Many health insurance plans cover preventive services such as vaccinations, screenings, and regular check-ups, helping detect diseases early and promoting better health management. Most importantly, having health insurance offers peace of mind, as it ensures that your medical expenses are covered, letting you focus on recovery without worrying about financial stress.

In many instances, the claim for such health insurance gets denied, leaving the recipient in dilemma.

What If The Claim Is Denied?

Understand the Reason for Denial: Review the letter or notification sent by your insurance company. It will explain the reason for the denial. Common reasons include coverage exclusions, missing documentation, or a lack of medical necessity. If the reason is unclear, call the insurance provider and ask for a detailed explanation.

There are certain reasons why health insurance claims get denied by the insurance companies and those may be:

1. Pre-existing health conditions can lead to rejection, as some insurers may view the risk as too high.

2. Incomplete or incorrect information on the application can result in denial, as accuracy is crucial.

3. Age limit issues, where applicants above a certain age may not be eligible for coverage.

4. Furthermore, individuals with high-risk occupations or lifestyles, such as hazardous jobs or dangerous habits, may face challenges in obtaining approval.

Appeal the Denial: Most insurance companies have an internal appeal process where you can dispute the decision. This usually involves submitting a written appeal, providing additional documents or evidence, and possibly getting a second review of your claim.

Gather any relevant medical records, letters from your doctor, and any other paperwork that supports your case (such as prior approvals or treatment history).

File a Grievance with the Insurance Ombudsman: If your claim is still denied after appealing within the insurance company, you can approach the Insurance Ombudsman in India. They can help resolve disputes between the insurer and the insured. Submit a complaint to the Ombudsman, providing all documentation and evidence related to the claim. The Ombudsman’s decision is binding on the insurer.

Seek Legal Action: If the issue remains unresolved, you may consider consulting with a lawyer who specializes in insurance law. They can help you understand your legal rights and whether you have grounds to take the matter to court. If the insurance company does not respond or if you feel the denial is unjust, you may file a case in the Consumer Court under the Consumer Protection Act.

Alternative Dispute Resolution (ADR): In some cases, insurers may offer an alternative dispute resolution mechanism, such as mediation or arbitration. This can help resolve the issue without going to court.