Claim Rejections vs Claims Repudiated in Health Insurance: What’s the Difference?

At a Glance

1. Claims Rejected vs Claims Repudiated: Understand the Difference
    
2. What is Claim Rejection?
    
3. What is Claim Repudiation?
    
4. How to Avoid Claim Rejection and Claim Repudiation?
    
5. What to Do If Your Health Insurance Claim Is Repudiated?
    
6. Final Thoughts – Get the Right Health Insurance Plan

Claims Rejected vs Claims Repudiated: Understand the Difference

When an insurer processes a health insurance claim submitted by the policyholder, they make a decision based on several factors. The claim can be:

• Approved – When all conditions are fulfilled, the insurer settles the claim and pays the amount.
   
• Rejected – In the event of technical mistakes, inadequate information, or policy failure, the claim does not get processed.
   
• Repudiated – When the insurer determines that the claim is unjustified in terms of the policy, it is repudiated.

Several policyholders get themselves into trouble if they view their claims as rejected or their claim status indicating "repudiated awaiting insurer concurrence, a claim rejected." Knowledge about these phrases may assist you in taking appropriate remedial steps.

What is Claim Rejection?

Claim rejection indicates that the insurance company failed to act on your claim because there was a problem in the process of submitting the claim. It is not a payment denial based on policy conditions but an invitation to correct mistakes and resubmit the claim.

Common Reasons for Claim Rejection:

1. Inadequate or inaccurate documentation – Absent reports, illegible prescriptions, or incomplete claim forms.
    
2. Policy lapse – If the policy had lapsed before the treatment, the claim wouldn't have been made.
    
3. Delay in submission of claim – Insurers set a claim submission deadline. Failing to meet it leads to rejection.
    
4. Patient information errors – Name mismatched, policy number incorrect, or hospital information incorrect.
    
5. Pre-authorization not received – Certain treatments need pre-approval from the insurer.

Can Rejected Claims be Resubmitted?

Yes. If your claim has been repudiated due to lack or erroneous information, you can make corrections and resubmit within the deadline set by the insurer. If the status of your claim is "repudiated awaiting insurer concurrence, claim rejected," the claim could be pending, hence you need to consult with your insurer.

What is Claim Repudiation?

Claim repudiation takes place when the insurer scrutinizes the claim and rejects it according to the terms of the policy. Contrary to rejection, repudiation implies the insurer does not view the claim as valid for payment.

Common Reasons for Claim Repudiation:

1. Non-disclosure of previous illness – In case you did not declare a sickness during policy purchase, your claim can be denied.
    
2. Fraudulent claims – In case the insurer discovers wrongful information or forged documents, the claim will be denied.
    
3. Policy exclusion treatment – Some conditions, like cosmetic surgery or treatments for infertility, might not be covered.
    
4. Uncovered hospital or treatment – Claims can be repudiated if the hospital is blacklisted or the treatment is not up to policy terms.
    
5. Breaches of policy conditions – If a policyholder does not comply with the claim process properly, the insurer can deny the claim.

Once a claim is denied, it becomes final unless appealed and won. The majority of policyholders face issues whereby their claims are denied due to miscommunication or unawareness of terms in a policy.

How to Avoid Claim Rejection and Claim Repudiation?

Filing a health insurance claim can be a difficult and stressful experience. Although health insurance is intended to offer financial assistance in the event of medical emergencies, most claims are rejected or repudiated because of mistakes, misrepresentation, or non-adherence to policy conditions. Nevertheless, by being proactive, policyholders can minimize the risk of claim rejection and claim repudiated significantly.

Following are tips to guarantee hassle-free claim processing:

How to Avoid Claim Rejection?

Claim rejection is when the insurer declines to settle the claim based on mistakes, incomplete documentation, or failure to follow submission rules. The bright side is that rejected claims are usually resubmittable after correction and will be accepted upon resubmission.

1. Double-Check Your Documents

Claim rejections can often occur because the documents are either incomplete or incorrectly completed. Before you submit the claim to the insurance agency, you need to check that all required documents are correct, clear, and complete.

• Medical documents & prescriptions: All relevant medical documents, such as diagnosis reports, prescriptions for medication, and the details about treatment should be properly signed by the authorized doctor. 
   
• Hospital bills & receipts: Check that all hospital invoices, pharmacy bills, and lab test reports all provide proof of treatment. 
   
• Insurance claim forms: The form should be filled with absolute correctness blank fields left empty or left inconsistent. 

Tip: Cross-check with the insurer's checklist all documents before submission for accountability post-fact.

2. Submit the Claim Within the Deadline

All insurance companies have a set period within which a claim has to be made. If a claim is lodged after the expiry of the period, the insurer may reject the claim. 

• For cashless claims – most insurers provide for and require hospitalization pre-authorization. So be sure to submit any request in time. 
   
• For reimbursement claims – it is necessary for all the appropriate documents to be sent within the limits set by the insurer immediately after discharge. 

Tip: Keep a schedule of claim submission dates and set reminders to avoid a last-minute rush.

3. Verify Personal Details Before Submission

Creating simple mistakes in the name, policy numbers, or even hospital details could have implications for your claim rejection. Always ensure:

• Names of policyholders match insurance records: spelling and formatting should be exactly like your insurance policy.
   
• Policy number and claim reference number need to be accurate: triple-check before submitting the claim.
   
• Hospital details are correct: ensure that the names and registration numbers of hospitals and doctors are detailed correctly.

Tip: A simple spelling error can cause your claim to be disallowed. Always proofread your claim form and documents before submitting.

4. Obtain Pre-Authorization If Required

Some medical procedures and treatments need prior approval from the insurance provider before hospitalization. If this is not done, there may be a denial of the claim.

• Pre-authorization is required in advance of surgery, treatment, or a costly diagnostic test.
   
• Submit requests for pre-authorization well before the appointment to await approval and proceed with treatment.

Tip: Always also check with the insurer or Third Party Administrator before hospitalizations to be on the safer side concerning any preauthorization requirements.

How to Avoid Claim Repudiation?

In claim repudiation, the insurer scrutinizes the claim and denies it under the exclusions or violations of the policy. Whereas a rejected claim can, indeed, undergo resubmission, repudiated claims stand to be resubmitted only if the repudiation was appealed against successfully.

1. Disclose All Medical Conditions Upfront

One prime reason for the repudiation of claims by insurers is the non-disclosure of pre-existing ailments. Even a slight hiding of medical history at the time of entering into an insurance contract may lead to repudiation of a claim in spite of paying a premium for several years. 

• A clear declaration of any pre-existing disease, like diabetes or hypertension or heart condition should be made while buying the policy. 
   
• No hiding of past surgical treatments: Insurers can access past medical records.
   
• Even minor ailments should be revealed if diagnosed before the issuance of the policy. 

Tip: Any inconsistencies in medical history may result in claim repudiation. It is advisable to be transparent during the purchasing of a policy to avoid complications in the future.

2. Read Your Policy Thoroughly

Claims are repudiated by a lot of policyholders just because they are not aware of the exclusions, waiting periods, and limitations included in their health insurance plan.

• Know the waiting period for pre-existing conditions because most of the plans require a waiting period of around two to four years before they cover these conditions.
   
• Know the exclusions from the policy, because procedures such as cosmetic surgery as well as infertility treatment may not be included in the costs, in addition to costs incurred from dental treatment.
   
• Check the limits on room rents, as some of the policies tend to be restrictive on eligibility for room accommodation through hospitals; exceeding the limit may affect the value of claims that can be made.

Tip: Go through the policy document and ask your insurer about any unclear clauses before buying the scheme.

3. Use Network Hospitals for Cashless Claims

You might get cashless treatment and claims repudiated if admitted in a non-network hospital

• Check the insurer's list of network hospitals before getting hospitalized on their website or app.
   
• Confirm with the billing department of the hospital that they will accept cashless payment treatment under your policy.
   
• For claim reimbursement in case of treatment at non-network hospitals, ensure cashless treatment is permitted by the policy. 

Tip: Network hospitals offer cashless treatment and carry less risk of disputes in claims.

Also Read: Top 10 Claim Settlement Ratio Health Insurance Companies in India

What to Do If Your Health Insurance Claim Is Repudiated?

If your health insurance claim is repudiated, follow these steps to address the issue:

1.  Understand the Reason – Insurers reject claims due to incomplete documents, policy exclusions, or incorrect information. Check the rejection letter and policy terms carefully.
    
2.  Contact the Insurer – Reach out to your insurer’s grievance redressal team for clarification. Provide any missing documents or rectify errors to reapply for the claim.
    
3. Escalate the Issue – If unsatisfied, escalate the complaint to the Insurance Ombudsman or IRDAI’s Grievance Redressal Cell through email or their online portal.
    
4. Seek Legal Help – If all else fails, you can file a case in the Consumer Court to challenge the rejection.

To avoid future repudiations, always disclose medical history, read policy exclusions, and submit accurate documents while filing claims.

Final Thoughts – Get the Right Health Insurance Plan

A policyholder needs to understand the difference between claim rejection and claim repudiation. While claim rejections can be remedied and resubmitted, repudiation of claims is a straight denial based on the policy terms.

To be saved from unnecessary tension, always: 

Read the policy in detail. 

• Disclose comprehensive details on medical conditions. 
• File a claim according to the correct process. 
• Keep records of all medical bills and prescriptions. 

Looking for a trustworthy health insurance plan? Explore OneAssure to find the most suitable health insurance policy for your needs today!