India’s New Delhi In India, policyholders who misinterpret the terms of their policy, neglect to disclose pre-existing medical issues, or make claims that are not covered by their policy are the main reasons why health insurance claims are denied.

Insurance industry experts stress that adequate knowledge and openness are necessary to guarantee a smooth claims procedure.

Reliance General Insurance CEO Rakesh Jain emphasized that many customers experience financial strain during medical crises as a result of their health insurance claims being denied.

According to him, “Rejection of claims majorly tends to occur on account of misunderstanding of policy wording, failure to disclose pre-existing conditions, procedural failures, or claims falling out of policy purview, etc.”

Jain emphasized how crucial it is to inform clients about these concerns. Additionally, he disclosed that while the health insurance market in India has grown, its penetration rate is still quite low, especially in non-metropolitan regions. The penetration rate of non-life insurance is now about 1%, whereas the worldwide average is around 3.9%.

Amit Chhabra, Policybazaar.com’s Chief Business Officer for General Insurance, said that claims are usually rejected for certain reasons. These include a lack of knowledge on the necessary paperwork, such as medical bills or discharge summaries, and policy terms, such as waiting periods.

Additionally, claims for treatments not covered by the coverage may be denied. False information or omission of crucial medical history, such as pre-existing diseases like diabetes or hypertension or lifestyle choices like smoking or consuming alcohol, are additional frequent causes.

According to him, “Insurers may deny a claim if the policyholder provides false medical information or fails to disclose pre-existing conditions like diabetes, hypertension, etc.”

The experts also emphasized the difficulties associated with extending health care coverage to rural and low-income individuals.

Jain pointed out that one of the biggest challenges in rural regions is still the absence of high-quality medical facilities.

“Even with insurance, accessibility to quality healthcare remains a concern due to a shortage of hospitals, diagnostic centers, and specialists,” he said. The effectiveness of insurance in these regions depends on fostering trust and bolstering the rural healthcare system.

Positively, Chhabra revealed that more than two-thirds of new health insurance purchasers now originate from areas outside of Tier-1 cities, indicating a rise in demand and awareness among lower-income and rural populations.

Both business titans praised government initiatives like as Ayushman Bharat.

While Chhabra pointed out that such programs have directly raised health insurance awareness and purchases in the places where they have been implemented, Jain referred to it as a “significant step” towards universal health care.

In the end, both experts agreed that the best way to enhance claim experiences and boost insurance penetration in India is to combine governmental and private initiatives, consumer education, and system simplification.

Customers may contact the Insurance Ombudsman, a government-appointed body that assists in resolving conflicts between policyholders and insurers, if they believe that an insurance provider has incorrectly denied their health insurance claim.

Policyholders may use this platform to pursue justice and make redressal claims without having to endure a drawn-out litigation procedure.