What To Do If You Are Denied Mediclaim

You might have health complications sooner or later, and for medical assistance, you visit a doctor and undergo hospitalization. So, people buy health insurance or Mediclaim Plans that provide coverage for all medical expenses for such medical emergencies. In exchange for monthly or yearly premiums, you merely expect financial assistance from the insurer in the event of serious health conditions and hospitalization.


The health insurance plans provide coverage for hospitalization expenses and daycare expenses and cover all the expenses of pre and post hospitalization like blood tests, x-rays, and other examination costs at least 30 days before hospitalization and 60 days post hospitalization, depending upon the medical emergency. Some people are surprised when they notice that the insurer has denied their Mediclaim under such grounds, which is unacceptable. Mediclaim settlements can be denied on various grounds.


Reasons for Medicliam Denial!

  • The insurer can deny the medical insurance or the Mediclaim settlements if the treatment or hospitalizations is excluded from the health insurance plan.
  • It can also be denied if the policyholder has pre-existing diseases that are not included in the plan. If claims are made on those specific diseases, then Mediclaim will be denied.
  • If the document provided for the claim settlement is incomplete or inappropriate, then the application for the claim can be denied.
  • The policyholder must inform the insurer within 48 hours of hospitalization. If claims are made within intimating the insurer within the policy’s timeframe, then the claim will be denied.
  • Clerical errors may also lead to the rejection of the Mediclaim.
  • Mediclaim can also be rejected if the treatment or tests are carried out at an unauthorized and unassociated network of laboratories and hospitals.


What to Do If You Are Denied Mediclaim?


If you find the grounds of denial are not satisfactory, then the first step is to approach the insurer’s grievance cell. If grievance cell never provides you satisfactory results, then IRDA ombudsman is the way to approach but within one year of the claim rejection. You need to provide a written complaint to the ombudsman. You also need to visit for a hearing and know the decision taken by the ombudsman. For a final verdict, you may also approach the consumer courts and forums.


The policyholders need to know exactly what their insurance policy covers and what the policy doesn’t cover to avoid rejections. This is essential to reduce the chance of rejections by the insurer. Some of the steps that you need to do when your Mediclaim is denied.

  • Discuss with Insurer – You need to have the list of questions handy with you before discussing with the insurer. According to the experts, when your Mediclaim is denied, the first thing you need to do is approach the insurer directly and contact the company’s bigwigs to accelerate the process. Ensure to provide only the copies of the original insurance bond, but not the originals. You may ask the questions that you have and try to understand why your Mediclaim has been denied. Even a small clerical error like incorrect code may lead to Mediclaim Rejection, and this type of rejections can be settled within the branch.
  • Appeal to Action – If all the tricks fail, then you may appeal your claim. You will find information on how to appeal your claim on the insurer’s written rejection notice or official website.

The last option is to approach the ombudsman and provide them with a written complaint mentioning all the details of your Mediclaim.

2 Comments

  1. Great information about why a claim would be denied and how to go about fixing it. Thanks for the post!

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