Why Your Insurance Claim Is Rejected and What to Do if It Is

When you secure an insurance policy, it gives you protection against potential risks and losses by being able to claim them from your insurer. But what happens when your claim is rejected? In that case, you can try contacting your insurer to prove your case in hopes for the claim to be accepted.

Are you in the midst of negotiating with your insurer over rejected claims? In this article, we will cover everything you need to know about insurance claims rejections and what you can do to try and get your insurer to cover your rejected claims.

5 Reasons for Insurance Claim Rejections

When your insurance claim is rejected, there is no need to feel dejected. Remember that insurance providers are stickers for details. When your claim is rejected it is important to review your claims application and your policy details to see if anything is out of place.

Whether you’ve had a claim rejected in the past or you’re completely new to the world of insurance, it pays to get inside your insurers’ head and understand why claims are rejected.

As a global insurance broker, Pacific Prime has over two decades of experience. We’ve helped clients handle claim rejections, and here are our top 5 reasons for why claim rejections occur.

1. Your Insurance Application Contains False Information

If you didn’t (or the insurer believes that you didn’t) answer all the questions on the insurance application form truthfully and accurately, such as failing to disclose a pre-existing medical condition, then the insurer might reject your claim.

2. You Didn’t Read the Fine Print of Your Insurance Policy

Insurance plans can vary from policy to policy, so it’s always important to read the policy details. In particular, you should refer to the table of benefits and any exclusions so that you’re crystal clear about what is and isn’t covered.

Here is a list of some of the most common health insurance exclusions:

• Conditions developed due to misuse of drugs or alcohol
• Experimental or unproven care
• Fertility treatment or testing
• Plastic and cosmetic surgery
• Treatment of psychological conditions
• Termination of pregnancy unless medically prescribed
• AIDS or HIV related diseases.
• Contraception, including sterilization
• Epidemics that are under the direction of the authorities
• Obesity treatments
• Sexual dysfunction
• Injuries inflicted whilst committing a terrorist act

3. Proper Claims Process Was Not Followed

The claims process may be extremely bureaucratic – the last thing you want to deal with when you’re recovering from a medical treatment – so it’s unsurprising if you aren’t able to follow the claims process down to the tee. However, this can be a reason for a claims rejection.

4. Incorrect Details on Your Claim Form

Similarly, you may have put down incomplete or inaccurate details on your claim form. Regardless of whether you did it intentionally or by mistake, there’s a high chance your claim will be rejected.

5. Your Insurer Refuses to Pay the Full Amount

Sometimes the insurer will reject your claim by refusing to pay the full amount. Instead, they will pay part of the amount. This may be because your insurance policy doesn’t have a high enough coverage or if you have (or the insurer believes that you have) inflated the value of your claim.

2 Steps to Take if Your Claim is Rejected

The first thing to do when your claim is rejected by your insurer is to remain calm, keep in mind that claim rejections are not the end of the world, there are still things you can try to get your claim approved. If your claim is rejected, try using the following 2 steps to rectify the situation.

1. Review Your Insurance Policy Documents

When your claim is rejected, your insurer will also provide you with the reason why your claim is rejected. This is a good time to start by fact-checking. Review your insurance policy documents thoroughly to see if the insurance claim rejection was fair or unfair.

If you believe it’s unfair, you should:

• Make sure you gave your insurer all the correct details, in both your insurance application and in your claim form.
• Highlight the exact wording in your policy that disproves the insurer’s reason for rejecting your claim. Is the wording ambiguous or poorly explained? Note that down too.
• Find any other documentation/evidence that relates to your policy or can be evidence to disprove the insurer’s reason for rejecting your claim.

2. Get in Touch with Your Insurer

After reviewing your insurance policy document, you can call your insurer and ask to speak to their complaint handlers. Alternatively, you can also write a formal letter of complaint and send it to the contact provided in the insurer’s complaints procedure.

The next step is to wait for the complaint to go through the insurer’s internal review process. You can also ask for details of this and periodic status updates if you prefer. Do note that the complaints procedure might take a while.

Note: This is where having an insurance broker like Pacific Prime by your side can really help. As brokers are impartial, we can deal with the insurer on your behalf, which saves you time and hassle.

Writing a Complaint Letter

If you’re dealing with the insurer directly and wish to write a complaint letter, There are a few tips and tricks that can help your case, from something as simple as making sure the word “complaint” is written on top to evidence to prove your case.

Here are a few things to include in the letter:

• Date
• Policyholder name and policy number
• Make sure the word ‘Complaint’ written clearly at the top
• Clear explanation of your complaint, state clearly why you think your claim shouldn’t have been rejected
• Supporting evidence for your claim
• Information on what you’d like the insurer to do to put things right

Simplify Your Claims Process with Pacific Prime

As you probably have realized, dealing with insurers is no piece of cake. But if you’ve secured your insurance policy through an insurance broker like Pacific Prime, we can take all the stress out of the process.

As a global insurance broker with over 20 years of experience in the industry, Pacific Prime’s team of experts can help you sort through countless plans from different insurers to help you find the best insurance plans.

We also provide value-added services like administration assistance, insurer liaison, and claims and renewal support to guide you throughout your entire insurance journey.

Are you an expat? If so, you’d be glad to know that we’re the expat’s go-to broker, as many of our insurance advisors are expats themselves, and we’ve got deep knowledge and expertise to support foreigners regarding health and health insurance matters in their new country of residence.

Whether you’re looking for expat medical insurance for your country of residence or an international health insurance plans to stay insured wherever your travel takes you, feel free to reach out to us for unbiased insurance advice, a tailored plan comparison, and a free quote today!

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Vista Nip

Content Creator at Pacific Prime

Vista is a content creator at Pacific Prime. With over 8 years of writing experience for online platforms on various topics such as luxury lifestyle and digital entertainment. He enjoys diving into complex and otherwise confusing topics, and creating easy-to-understand content for the readers to help them navigate through the topic - something that’s perfectly aligned with Pacific Prime’s motto of ‘simplifying insurance’.

Born and raised in the cultural melting pot that is Hong Kong, and having studied at an international school, Vista has developed a multicultural perspective that he uses in his writing and strives to connect to people of different backgrounds.

In his free time, Vista enjoys immersing himself in different worlds, from video games to light novels and movies. His hobbies help him expand his writing style by putting himself in the point-of-view of different people and characters.

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