Has the Insurer denied your claim? Or made a partial payment? There could be many reasons for full or part rejection of your health insurance claim. Some of these are listed below:

• Pre existing disease
• Existing disease may not be covered for 3 to 4 years
• Reasonable & Customary Clause
• Expenses on treatment during hospitalization should be comparable to similar hospitals in that area
• Hospitalization for evaluation
• If you have no illness but just get admitted for examination, your claim is likely to be denied
• Permanent Exclusions
• Some illnesses like heart disease, diabetes etc. may not be covered permanently, Also illnesses resulting from use of alcohol or drugs are not covered
• Specified diseases
• A list of slow growing illnesses like Cataract may not be covered for up to 2 years
• Initial 30 days
• No cover for any illness except accident
• Hospital norms
• The hospital should meet IRDAI norms
• OPD treatment
• most policies do not cover routine consultations with doctors etc.
• Insured not covered
• May be the admitted person is not covered under the policy
• Surgeon
• If the surgeon is a close family member, claim may be rejected
• Room limits
• If you stay in a higher category room than your eligibility, proportionate deductions will be made
• Sub Limits
• For example, if there is a sub limit of Rs.40k on Cataract, payout will be limited to that even if the sum insured is say, Rs.5 lakhs
• Particular disease
• policy clauses may exclude certain illnesses or conditions

One needs to be aware of policy exclusions to avoid trauma at the time of claim. Seek help from your advisor if you are not able to comprehend a particular policy clause. Health insurance has many clauses and it makes sense to understand them before purchasing a policy.