Filing a health insurance claim sounds simple — but even tiny errors or oversights can lead to partial settlements or outright rejections, leaving you to pay large medical bills yourself. In India, a significant number of health insurance grievances relate to claim issues like lapses, misinterpretations, missing documents, or undisclosed conditions.

❗ Common Mistakes That Can Cost You Big

1. Not Disclosing Medical history Honestly

Failing to declare pre‑existing conditions — even common ones like diabetes or hypertension — when buying a policy is one of the biggest reasons insurers reject claims.

✔ Tip: Disclose everything — major and minor health issues — accurately at the time of application.

2. Ignoring Your Policy’s Terms, Inclusions & Exclusions

Every plan has specific coverage limits, exclusions, waiting periods, sub‑limits (e.g., room rent cap), and terms for procedures. Claiming for something not covered will often be rejected.

✔ Tip: read your policy document thoroughly. Ask the insurer about anything that’s unclear before a claim arises.

3. Missing Claim Deadlines

Insurance policies include strict deadlines for notifying the insurer of a hospitalisation or treatment and for submitting claim documents. Missing these can lead to rejection.

✔ Tip: Notify your insurer immediately after hospitalisation — ideally within 24–48 hours — and file documents as soon as they’re available.

4. Incomplete or Incorrect Documentation

Small mistakes like wrong dates, missing signatures, missing discharge summaries, mismatched names, or forgotten reports can delay or deny your claim.

✔ Tip: Use a checklist of required documents (policy copy, bills, prescriptions, discharge reports, etc.) and keep originals and copies ready.

5. Policy Lapse Due to Missed Premiums

If your health insurance lapses – even briefly – no claim can be made for the period of lapse.

✔ Tip: Set reminders or opt for auto‑debit so premiums are always paid on time.

6. Seeking Treatment Outside the Network (for Cashless)

For cashless claims, treatment typically needs to be at a network hospital approved by your insurer. Going outside that network without consent can lead to complications or partial claims.

✔ Tip: Always verify that the hospital or clinic is within your insurer’s network before admission.

7. Claiming for Non‑Covered or OPD/Daycare Procedures

Some treatments (like daycare procedures, OPD consultations) are not automatically covered unless the policy specifically lists them.

✔ Tip: Check whether procedures are covered or if you need additional riders or riders covering OPD/daycare.

💡 Why These Mistakes Matter

According to data and customer reports, claim rejection rates can be high due to avoidable errors like non‑disclosure, waiting periods not completed, and documentation issues. One estimate suggests roughly 16–25% of claims get rejected or partially paid due to such mistakes, and complaints in the insurance sector — particularly around claims — have been rising.

Even when rejection feels unfair, navigating the grievance redressal process (through insurer appeals, IRDAI complaints, or ombudsman routes) can be slow and stressful, especially if serious medical expenses are involved.

🛡️ Simple Steps to Protect Yourself and Your Claim

✅ Understand your policy (inclusions, exclusions, waiting periods).
✅ Disclose all health information honestly at purchase time.
✅ Pay premiums on time to keep your policy active.
✅ Seek pre‑authorization from your insurer for planned treatments.
✅ Notify the insurer promptly after hospitalisation.
✅ Keep accurate records and complete documentation.
✅ Confirm network hospital status before cashless treatments.
✅ Follow up quickly when the insurer asks for more information.

📌 In Summary

👇 These small preventive steps can make a huge difference at claim time:

Mistake

Consequence

Not disclosing medical history

Claim rejection

Missing claim deadline

Claim denied

Incomplete documents

Delayed or rejected claims

Policy lapse

No coverage at all

Exceeding sub‑limits

Partial payout

Wrong treatment category

Exclusion rejection

💡 Key takeaway: health insurance is meant to protect you financially when you need it most — but simple mistakes can undo that protection. Careful planning, record‑keeping, and communication with your insurer can help ensure your claims are accepted and your financial security remains intact.

 

Disclaimer:

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any agency, organization, employer, or company. All information provided is for general informational purposes only. While every effort has been made to ensure accuracy, we make no representations or warranties of any kind, express or implied, about the completeness, reliability, or suitability of the information contained herein. Readers are advised to verify facts and seek professional advice where necessary. Any reliance placed on such information is strictly at the reader’s own risk.