Why Would Health Insurance Deny a Claim 
                     Why Would Health Insurance Deny a 
Claim?
Whenever you purchase a health insurance cover, you are under the assumption 
that the insurance company will come in during such medical crises and clear 
your bills. Most policy holders however are shocked to realize that their claim is 
not accepted. It is best to have a knowledge on the general causes of refusals so 
that you can eliminate needless heartbreaks. There are two reasons, which we 
explore in this blog post, why insurance claims are denied and how to raise the 
probability that the insurance claim will be approved.
Common Reasons for Claim Denial
● Failure to disclose Pre-Existing Conditions:
The failure to report the pre-existing medical conditions during 
purchase of the policy is also among the most common reasons that 
lead to denial of claims.
Such conditions as diabetes, high blood pressure, previous 
surgeries, even though they might be considered minor, are 
considered as material information. When the insurers find them 
after a claim, they usually reject it citing non-disclosure.
● Waiting Period Uncompleted:
Waiting periods are associated with almost every health insurance 
plan. In some diseases or even known conditions the coverage is 
only valid after some certain period- it might be 1, 2 or may be 
more years. Claiming anything before this time is likely to be thrown 
away.
● Treatment or Procedure Not covered (Policy Exclusions):
All the policies come with a list of exclusions - treatments or 
conditions not covered. These may be cosmetic surgery, some 
dental surgery, alternative medicine, or even some day care/OPD 
surgery. Claims made on omitted treatments are virtually 
rejected.
● Incomprehensive or Substandard Documentation:
Insurers demand paperwork, with extensive documentation: 
hospital bills, prescription, discharge summary, diagnostic report, 
proof of identification etc. Claims are frequently denied by insurers 
in case documents are lost, names/ages do not match, or because 
of some errors.
● Policy Lapsed / No Premiums paid / Not in covered condition:
Without renewing the policy, or paying the premium, which lapses, 
or there is a lapse of time, the insurance ceases to be in operation. 
Any claim in a lapsed or inactive policy will be rejected.
● Late claim filing or omitted steps (e.g. Pre-Authorization):
Most insurers require that when the hospitalisation or treatment 
is to be claimed, it must be intimated within a given period (e.g., 
24 hours after admission in case of an emergency). The failure to 
present the required pre-authorizations or the inability to submit 
them on time can be taken as a refusal.
● Medical Necessity/Treatment Justification Problems:
Insurers occasionally assess the necessity of the hospitalisation or 
treatment whether it was medically necessary. In case your process 
is considered as elective, avoidable or not a necessity that is 
plainly needed, the insurance company might refuse to pay the 
claim based on non-medical necessity.
● Going above Policy Limits (Room Rent Caps, Sub-limits, Benefit Limits): 
Sub-limits may be imposed by the health plans such as a limit on 
renting rooms, on specific procedures or limit on amount of 
coverage. In case a claim claims beyond such limits, insurers can 
decline it or pay it in part.
How to Avoid Claim Rejection — Tips from Claimnikalwao
At Claimnikalwao, we believe awareness and careful preparation are the 
keys to making your health insurance work when you need it. Here are 
simple practices to help avoid common pitfalls:
● Always be completely honest about your medical history, even the 
most minor conditions you might have had, it will always pay off.
● Learn your policy: Be conversant with waiting periods, coverage 
inclusions and exclusions, sub-limits, room-rent caps and any 
other specials.
● Maintain full and correct documentation: hospital bills, prescription 
slips, discharge notes, and diagnostic reports- check names, dates 
and signatures.
● Make claims in time and go through the necessary procedures 
(such as pre-authorization or prior intimation towards planned 
hospitalization).
● Make sure you have a continuous cover- do not allow the lapses in 
payments and take out fresh cover in time.
Final Thoughts
A denied health insurance claim isn’t always due to unfair or arbitrary 
decisions. Often, it stems from misunderstandings, oversight, or simple 
errors. By being proactive, honest, and attentive to policy details, you can 
significantly reduce the risk of rejection.
At Claimnikalwao, our goal is to help policyholders navigate health 
insurance — understand what’s covered, what’s not, and how to maximize 
your chances of a smooth claim settlement. Follow these practices to 
ensure your insurance truly works when you need it most.