The diagnosis of a critical illness is a devastating blow in itself, and if the insurance company rejects your claim, the mental and financial stress is compounded. But did you know that a claim rejection doesn’t necessarily mean you won’t receive your money? Often, companies reject claims due to technical flaws or lack of information, which can be reversed with proper procedures and solid evidence.
Analyzing the Policy Terms
As soon as you receive a claim rejection letter, carefully review your policy documents. Companies often deny claims, citing “conditions.” You need to check whether your illness is included in the “Critical Illness” list.
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For example, many policies cover 32 to 40 illnesses, such as bacterial meningitis or cancer. If the illness listed in your medical certificate matches the policy terminology, the company cannot reject it. To be prepared, obtain a clear certificate from your doctor that matches the policy terminology.
Ultimate weapon for getting your claim approved
Insurance companies operate on paper. If you have solid medical evidence, challenging a company’s rejection becomes easier. Keep hospital records, discharge summaries, and lab reports organized.
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Reports like MRI, CT scan, or biopsy play a crucial role in proving the severity of the illness. If the illness is brain or nerve-related, written evidence from a specialist stating that the problem has persisted for six weeks or more makes the case much stronger. A specific doctor’s certificate clearly stating that the patient’s condition falls under the policy’s definition of “critical” is the key to getting the claim approved.
Relief from the Insurance Company
When the insurance company refuses to listen to you, instead of giving up, you should approach the appropriate forum. First, write a formal letter to the company’s Grievance Redressal Team (Complaint Cell). In it, mention the policy terms that favor you and re-attach all medical documents.
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If the company doesn’t provide a satisfactory response within 15 to 30 days or persists in its incorrect decision, the next step is to contact the Insurance Ombudsman. The process of approaching the Ombudsman is completely free and does not require a lawyer. The Ombudsman thoroughly examines the documents from both parties, and it has often been observed that if there is solid medical evidence, the decision is in the customer’s favor.
How to Avoid Fraud and Rejection
Claims are often rejected because pre-existing diseases are concealed at the time of policy purchase. Always disclose your medical history with unwavering honesty. Also, don’t share your OTP or login password with anyone you don’t know when filing a claim. Correct and accurate information is your greatest protection and shield.