Why do health insurance claims get rejected?

A health policy is bought for one day — the day someone in the family is in hospital. Yet many claims are cut or rejected for reasons that could have been avoided at the time of buying. Here are the most common ones.

1. A health condition was not declared

The proposal form asks about illnesses, medicines, past surgeries, smoking and alcohol. If an answer is missing or wrong, the insurer may reject a claim later — even for an unrelated illness. Declaring a condition may mean a waiting period or a loading on the premium, but it keeps your claims safe.

Under IRDAI rules, once a policy has run continuously for 60 months (5 years), the insurer cannot question it for non-disclosure, except in cases of proven fraud. Until then, honest answers matter most.

2. The waiting period was not over

• Initial waiting period: usually 30 days from the start of a new policy (accidents are normally covered from day one).
• Specific illnesses: some treatments such as cataract or hernia often have a waiting period of one to two years.
• Pre-existing diseases: covered only after the waiting period written in your policy (IRDAI caps it at three years).

Waiting periods already served are carried forward when you renew on time or port your policy — another reason never to let a policy lapse.

3. Room rent and sub-limits

Many policies limit the room rent per day. If you choose a costlier room, not only the room charge but many other charges may be reduced in the same proportion. Some policies also cap the amount for specific treatments. Read these limits before you buy, not at the hospital desk.

4. The treatment is not covered

Every policy has a list of exclusions. Treatment that does not need hospitalisation (other than listed day-care procedures), cosmetic treatment and some other items are commonly excluded. The policy wording is the final word.

5. Late information and missing documents

Tell the insurer before a planned admission, or as soon as possible in an emergency. Keep the discharge summary, all bills, reports, prescriptions and payment receipts. Incomplete papers are a common reason for delays.

A simple checklist before you buy

• Fill the proposal form yourself, or read every answer before you sign.
• Read the room-rent limit, co-payment, sub-limits and waiting periods.
• Keep the policy document and the insurer's claim number saved on your phone.
• Renew before the due date, every year.

Not sure how much cover your family needs? Try our health cover calculator.