health insurance claims

Why Was My Health Insurance Claim Rejected?

25th May 2021 8min read 183 views

Everybody needs to have a good health insurance plan today. The world changes constantly, and we never know when an illness or accident could leave us in hospital for a few days. As we’ve learned over the last year, nothing is more important to us than our good health. Unfortunately, a rejected claim could leave you scrambling to take care of hospital and medical bills in an emergency. To ensure you steer clear of this issue, here’s a look at the most common reasons why health insurance claims get rejected:

Crossing the Limit

Most people make the mistake of assuming everything is covered up to the maximum sum insured amount. If you look at your health policy documents, you’ll see that there are caps on how much you can claim for different things. For example, your health insurance company may offer a maximum room rent limit of just INR 4,000 per day. If you end up being admitted in a room that costs INR 6,000 per day, you cannot claim the full amount. If you file a claim without checking these limits, your request will get rejected.

Misrepresentation of Facts

It’s crucial to be honest whenever you deal with your insurance provider. If you misrepresent the truth or try and lie to get a better deal, you could end up in a lot of hot water. Any claim that you make that suppresses or misrepresents facts will get rejected. Remember, all the top health insurance companies in India will do their own checks to verify each claim.

Waiting Period Claims

Every health insurance plan has a few waiting limits you need to know about. There’s an initial waiting period of 30 days from the date the policy is issued for the first time. During this time, you cannot make any non-emergency claims. Next, there’s a pre-existing disease waiting period. Depending on which tier of the Edelweiss health insurance plan you’ve selected, this could range from two years to four years. If you require treatment for a pre-existing or related illness during this time, you cannot make a claim against your policy. So, to avoid claim rejection, make sure you read through your policy documents carefully and only file valid claims.

Exceeded the Time Limit

You need to intimate your health insurance company about a claim properly. For pre-planned hospital admissions, you must inform the company at least 72 hours before you get to the hospital. In emergency scenarios, you can get in touch with the TPT administrator at the network hospital within 24 hours of admission. You also need to file the claim on time after your discharge. If you miss intimating your insurance company or file the claim too late, it will likely get rejected.

Procedure Is Out of Scope

Your health insurance plan does not cover all kinds of medical treatments. Certain procedures, such as cosmetic dental surgery is not covered unless it’s medically required after an accident. Any claim that you file for a procedure or treatment that is not covered will lead to your claim getting rejected.


As you can see, the easiest way to avoid claim rejection is by reading your Edelweiss health insurance policy documents carefully. Make note of all the waiting periods and exclusions right at the start. By doing this, you will avoid filing claims that could potentially get rejected.

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