11 Reasons Why Your Cashless Health Claims Can Get Denied

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Getting health insurance with the cashless treatment benefit feels like a big relief for a policyholder. With no upfront payment, hospital bills are handled directly by the insurer, and it provides a smoother experience when you or a loved one needs medical care.
However, many policyholders are surprised when their cashless health claims get rejected or denied by insurers, leaving them scrambling for funds. This blog highlights the common reasons behind the rejection of cashless health insurance claims.

Why Cashless Health Claims Get Denied?

A cashless health insurance claim allows policyholders to enjoy the best treatment for hospitalisation without paying upfront. However, certain common mistakes from the policyholders may lead to your cashless health insurance being rejected.

Let's check the top 11 reasons for claim rejection and what you need to keep in mind when buying or renewing health insurance:

1. The Hospital Is Not In The Insurer's Network

Cashless claims generally work only when you get treated at a hospital that's part of the insurer's approved network. If you go to a non-network or even a blocked hospital, your cashless insurance claim may be rejected. This is particularly important for those holding a family health insurance plan, where different family members may prefer different hospitals.

2. Wrong Or Incomplete Pre-authorisation Form

Before starting the treatment, every hospital sends a pre-authorisation request form, mentioning the doctor's note, treatment expenses, prescriptions, and other details to the insurance company. If this form is not filled properly or in case of missing information, the insurer will reject the claim.
Families with multiple insured members should ensure all pre-authorisation forms are correctly submitted for each individual.

3. Delay In Sending The Pre-authorisation Request

Even if the form is correct, if the hospital delays the submission of the pre-authorisation request (especially in emergencies), the insurance company may reject the cashless health claims. This can be a challenge for policies covering multiple members simultaneously.

4. Treatment Is Not Covered Under The Policy

Every health insurance plan has some limitations for certain treatment procedures, like cosmetic surgery, dental work, or alternative therapies. So, check what treatments are covered under your plan. Otherwise, the insurer will reject the claim request.

5. Break In Policy Renewal

If you allowed the policy to lapse (missed a premium payment or failed renewal), the cashless health insurance benefit may no longer be valid. So, pay your premiums on time to enjoy cashless health insurance benefits.

6. Waiting Period Not Completed

Many policies impose a waiting period (between 1 and 3 years) before covering pre-existing conditions or certain treatments. If you seek treatment during this waiting period, the insurer can deny the claim. This is important for all members, as some may still be within the waiting period.

7. Room Rent Limit Mismatch

Some insurers cap the room rent they will cover. If you choose a room that exceeds this limit, your claim might be rejected or the excess charged to you.

8. Non-Disclosure Of Health History

If you did not inform the insurer about a pre-existing disease (PED) or past treatment when you bought the policy, or if you misrepresented your medical history, the insurer may reject your cashless insurance claim.

9. Treatment Is Seen As Non-medical Or Unnecessary

Sometimes insurance companies decide that a hospitalisation wasn't medically necessary. You could be treated on an outpatient basis, or even if it didn't require hospitalisation. In such cases, a health insurance claim may happen.

10. Document Mismatches Or Errors

Policyholders commit mistakes in documentation. The company checks all documents, like the form, prescriptions, expected treatment expenses, and other details. If they find any discrepancy in the documents, they will not approve the cashless claim request.

11. Fraud Or Suspected Misrepresentation

Never try to hide any crucial information (past treatment or a hidden medical condition) from your insurance company. If the company suspects any fraud or finds misrepresentation of facts, it rejects the claim request immediately. Always be honest from the beginning for a smoother claim approval.

Cashless health insurance is a valuable benefit for a policyholder. However, you will enjoy the benefits only if you follow the policy rule. Before opting for a treatment, go through the policy details, including exclusions, benefits, waiting periods, and room-rent limitations. Also, keep all the documents transparent and accurate. Only in this way can you save yourself from the financial burden and unnecessary stress during the crucial hours.