Recently, a top-notch insurer rejected my mediclaim for not informing the insurer that I was a non-habitual smoker. While getting the insurance policy I had stated that I was not a smoker but somehow they found out from my friends and family, or not sure from where, that I was a smoker. I was admitted to a hospital for a lung infection recently and they rejected the claim saying that I falsified my personal info. Under what other grounds can insurance companies reject claims?

Ans: Insurance companies can reject claims for various reasons beyond falsified information like undisclosed smoking habits.
Here are eight common grounds for claim rejection. Please do not ignore these if you want your claim settlement process to happen smoothly:

1. Pre-existing conditions: If the policyholder has a pre-existing medical condition that wasn’t disclosed or was misrepresented at the time of purchasing the policy, the insurer might reject claims related to that condition.

2. Policy exclusions: Certain treatments, procedures, or conditions may not be covered by your insurance policy. If your claim falls under these exclusions, it can be rejected.

3. Non-disclosure of information: Besides smoking habits, any undisclosed information relevant to your health or lifestyle (such as pre-existing illnesses, risky hobbies, etc.) that could impact the policy terms might lead to claim rejection.

4. Lapsed or non-payment of premiums: If you fail to pay premiums within the grace period or if your policy has lapsed due to non-payment, claims during that period might get rejected.

5. Policy limits or maximums: If the claimed amount exceeds the policy’s maximum coverage limit, the insurer might reject the excess amount.

6. Fraud or misrepresentation: Any fraudulent claims, providing false information intentionally, or submitting falsified documents can lead to claim rejection.

7. Waiting periods: Some policies have waiting periods for specific conditions or treatments. If a claim is made within this waiting period, it might be rejected.

8. Policy violations: If the claim is in violation of policy terms or conditions, it can be rejected. For instance, seeking treatment from a non-network provider in cases where network providers are mandated.

If your claim has been rejected, review your policy documents thoroughly to understand the grounds on which the rejection was based. It’s also worth considering appealing the decision if you believe the rejection was made in error or if you have additional information to provide. Consulting with a legal or insurance professional might also help navigate the appeals process or understand your rights in such situations.