Why Do Health Insurance Claims Get Rejected? Top 7 Mistakes to Avoid

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Main purpose of taking a health insurance policy is to have peace of mind during medical emergencies and preventing these events to turn into financial burdens. But what if, your claim gets rejected? — Unfortunately, health insurance claim rejection is common problem in India and you will realize this when you see the stats at Consumer Forums or Grievances. Most of these rejections are due to following listed common reasons and they are often avoidable mistakes.

Today we will walk you through these top 7 reasons why health insurance claims get rejected, and how you can avoid them to ensure hassle-free approval.

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1. Top Listed Reason for Rejections: Non-Disclosure of Pre-Existing Diseases

This is the #1 reason for health claim rejections in India and is arguably due to poor insurance knowledge in the society.

At the time of buying a health insurance policy, you're required to disclose all the details truly as it is. You need to mention of any pre-existing diseases (PEDs) like hypertension, diabetes, thyroid issues, or heart problems or any other condition. If you hide this vital information, your insurer CAN LEGALLY reject your claim if the taken treatment is related to the undisclosed illness.

In my experience, I have dealt with huge number of people, even in my circle, who have opinion that, if I don't disclose my previous health conditions, how come insurance companies will come to know. This is just like, no one is watching the traffic signal, let me cross it, what will happen. This is the same mentality in our society. Lack of insurance conceptual awareness and thin/weak integrity are main reasons behind this situation, as far as I can know. 

✅ How to Avoid:

  • Be honest and transparent while filling out proposal form and disclosures. Don't think insurers can't know anything. Remember, they are expert and skilled enough to find out such non-disclosures. It is their job to find and weed out such claims. 

  • Better to get a medical check-up if you are over 45 years or have any health problems.

  • Select health insurance policies with shorter waiting periods for PEDs.

🧠 Related: Health Insurance Plans with Zero or Minimal Waiting Periods

2. Claiming During the Waiting Period, particularly Disease-Specific Waiting Period

Almost all health policies come with:

  • Initial waiting period (of 30 days of fresh policy, not applicable for renewals)

  • Waiting period for Pre Existing Diseases (2–4 years)

  • Disease specific waiting period (like hernia, cataracts). Listed conditions have 1 year / 2 year waiting periods. Read here: 

If claim is raised during this waiting period, it will be rejected as per terms & conditions of the policy.

✅ How to Avoid:

  • Read and understand your policy document carefully, particularly the waiting period section.

  • Avoid applying for claims during waiting periods, unless it’s an emergency.

  • Search for insurers who waive of waiting periods.

🧾 Pro Tip: Ask your insurance company for explaining the coverage under the policy or ask for a benefit illustration or a clause summary at the time of buying the policy.

3. Claims for Treatments that are Not Covered Under the Policy

There are some exclusions in most of health policies. Some treatments are not covered, regardless of the waiting periods. Sometimes, the treatment you took might not be part of the inclusions in your health insurance plan. Commonly the exclusions include: 

  • Cosmetic surgeries (as they are not usually considered as medical emergencies)

  • Dental treatments (unless necessitated due to accidents)

  • Infertility procedures (most policies don't cover)

  • Alternative treatments (are covered but up to certain sum insured limits)

✅ How to Avoid:

  • Read the policy documents for exclusions section for treatments that are not covered.

  • Confirm with your insurance company or TPA before undergoing treatment.

  • Select comprehensive plans that cover AYUSH, maternity, and OPD as required.

4. Claim Procedure Lapses: Submission of Incorrect or Incomplete Documents

All claims are to be supported by relevant and necessary documents, whether it is health policy or property insurance or any other department. Even valid health claims can get rejected if:

  • Necessary documents are not submitted

  • Bills are not clear

  • Diagnosis reports are not attached

Note that this is very common reason of claim rejection particularly in reimbursement claims, where paperwork is crucial. Make sure to understand the claim documents and submit all docs at once.

✅ How to Avoid:

  • Submit original bills, reports, and importantly discharge summary. Mandatorily take photocopy of all the documents that you are submitting. 

  • Usually annexure to claim form will have insurer’s checklist of required documents.

  • Also, keep a soft copy / scanned backup of all documents in case of loss. Nowadays it is easy to take soft copy of documents on phone through latest document scanning apps.

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5.  Delay in Intimating the Insurance Company about your Claim

It is understandable that during medical emergencies we all will be in stress, it is common to miss out intimating the claim on time to the insurance company. For the sake of avoiding fake claims and probable fraud rings, insurers require timely intimation. Most commonly, people delay intimating their insurer about hospitalization, particularly in emergency situations. As per policy conditions, policies require:

  • Claim Intimation within 24 hours for emergency admissions

  • Advance Intimation: Pre-authorization 48–72 hours prior to planned procedures

Failure to comply timelines can result in outright claim rejection. However, if there is slight delay and there is proper justifications, based on the case to case situation, insurer can condone delay in intimation upon such request from the claimant. 

✅ How to Avoid:

  • Keep ready: insurer’s toll-free number, TPA contact and your TPA UHID (your id number) on your phone and share it with your family members group so that all your family members know it.

  • Intimate the claim as soon as possible—right from the hospital, there will be insurance / TPA helpdesk at most of the major hospitals.

  • Assign this claim related job to one family member in case you're admitted. All correspondence done by a single person will be more efficient because he / she can track easily.

6. Claim Made After Policy Lapsed or Premium Not Paid on Time

If your health policy has expired and not renewed, coverage ceases to exist i.e. coverage stops. Even a 1-day lapse can make claims rejected. Also, note that policy coverage also stops in case of auto-debit failures or technical faults or agent / broker faults. It is your responsibility to ensure that policy is in force and is renewed on / before time. 

Read here: What happens if policy expires after I am admitted in the hospital?

✅ How to Avoid:

  • Enable auto-debit feature or set reminders well before renewal date. Still, ensure that auto-debit has functioned properly and policy is generated / renewed.

  • Ensure your address / email / mobile number is updated with the insurer.

  • Don't wait for last dates or reminders. Renew your policy well in advance to avoid break-in policy situations.

    Read here: What happens if any claim arises during Break-in Period before Policy Renewal?

🛡️ Tip: Once a policy is lapsed, some insurers impose medical underwriting again i.e. your application for renewal is subject to latest underwriting guidelines —making it tougher to get the policy.

7. Chosen Hospital or Treatment Not Empaneled

Often insurers offer cashless treatment only in network hospitals. If you get treatment in a non-network or blacklisted hospital, your cashless request will be reject and you might have to avail reimbursement. Sometimes, claim may be denied or only partially reimbursed.

✅ How to Avoid:

  • For cashless and easy process, check the list of empaneled hospitals. Make sure to know which hospitals are empaneled in your area / locality.

  • If you have already decided where to get the treatment, check if cashless service is available at that hospital.

  • Technologia tip: utilize your insurer’s website or mobile app to find network hospitals nearby.

📌 Final Thoughts

Health insurance claim rejection can feel like personal betrayal, as it will make you question the purpose of health insurance concept itself — but in most cases, rejections are due to policyholder oversight or intentional mistake or misunderstanding. By being properly informed, honest and careful, you can reduce the chances of health claim denial.

🧩 Summary of Top Mistakes to Avoid:

Reason How to Avoid
Non-disclosure of illness Full medical disclosure
Claiming during waiting period Know waiting clauses
Wrong/unclear documents Submit proper paperwork
Delay in intimation Inform insurer immediately
Lapsed policy Timely renewal
Non-empanelled hospital Check hospital network
Treatment exclusion Read policy terms

🙋 Still Worried About Claim Rejection?

Don’t worry. Read here: What to do if My Health Claim is Rejected?

Have any questions to ask or experiences to share? Drop in the comments section below. Let’s share each others knowledge and help each other in making smarter insurance decisions.

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