Compare cited reasons with policy terms before challenging decision

Health and general insurers paid 82 per cent of claims by volume and 71.3 per cent by value (₹1.17 crore), according to the Insurance Regulatory and Development Authority of India's (Irdai's) annual report for 2023-24.

- HIMAIJ PATEL

Of the remaining 28.7 per cent by value, nearly 13 per cent were rejected and over 9 per cent repudiated.

Understanding the distinction between rejection and repudiation is crucial. "Rejection occurs before a review or assessment, often due to incomplete information or errors. It is not permanent and can be reversed. Repudiation, on the other hand, happens when an insurer reviews a claim, and decides it is not covered under a policy's clauses. It is permanent," says Shilpa Arora, co-founder and chief operating officer, Insurance Samadhan.

Why do claims get denied?

Health insurance claims are often denied due to exclusions in policy terms. Buyers frequently overlook the fine print or misinterpret clauses.

"Permanent exclusions, hospitalization during waiting periods, non-disclosure of pre-existing conditions, treatment at excluded hospitals, and premium payment lapses are the main reasons for rejections," says Abhijeet Ghosh, joint executive president, Star Health and Allied Insurance.