Understanding Health Insurance Claim Rejections for Heart Disease in India

On World Heart Day 2024, it is crucial to highlight the significant reasons behind the rejection of health insurance claims related to heart ailments in India. As the country remains a leading contributor to heart-related diseases, understanding these factors can help individuals better navigate their health insurance options.

According to a survey by The Lancet, the early onset of heart disease among Indians often results in increased treatment costs, which include the costs of medications and hospitalization. While comprehensive health insurance can cover such expenses, many claims are denied due to several reasons.

A primary reason for rejection is the non-disclosure of pre-existing diseases (PEDs). “It is always advisable for people to disclose their health conditions when taking health insurance. Failure to do so may lead to rejection of claims in the future,” advised Manish Dodeja, Head of Claims & Underwriting at Care Health Insurance. Conditions such as high cholesterol, hypertension, and high blood sugar levels, if not disclosed at the time of purchasing insurance, may lead to claim denials.

Additionally, health insurance policies often have a waiting period for treating specific diseases, including cardiovascular conditions. “We have seen cases of non-disclosure of pre-existing conditions. For example, if somebody has been suffering from a heart condition or had a medical history related to the heart or any other condition that has not been disclosed to the insurance company. In that scenario, the insurance company may reject the claim, citing non-disclosure,” explained Siddharth Singhal, Business Head of Health Insurance at Policybazaar.com.

Singhal further described situations where claims might be rejected due to waiting periods. “If a person declares that he has a heart condition, then the insurance company would initially put a waiting period of three years. If the person claims for heart disease treatment within these three years, the insurance company does not consider the claim favorable.”

Another factor contributing to claim denials is the exclusion of specific treatments under certain policies. Dodeja pointed out that some health insurance plans may not cover specific procedures or medications, making it vital for policyholders to thoroughly understand these exclusions before committing to a policy.

Experts recommend full disclosure of health conditions, gaining knowledge of policy coverage and waiting periods, opting for specialized health insurance, and using network hospitals for treatment as preventative measures against claim denials.

“If your health insurance claim is rejected, the first step is to carefully review the rejection letter to understand the reason behind the denial, which could be due to missing documentation or policy-related issues. Once you have clarity, you can appeal to your insurer, providing the additional documentation or correcting errors in your submission, if that is the reason,” added Dodeja.

For unresolved claims, policyholders can seek assistance from the Insurance Ombudsman or pursue legal action if necessary, as noted by Singhal.