Watch This Before Buying Health Insurance | 100% Claim Pass Guaranteed

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Imagine this: You go online, carefully select a health insurance plan worth ₹50 lakhs, add some riders, and diligently pay your premiums on time. Everything seems perfect. But then, an unfortunate day arrives when hospitalization becomes necessary.

Now, you have two hospital options in your locality:

  1. Three-Star Private Limited Hospital – Approximate cost: ₹5 lakhs
  2. Five-Star Private Limited Hospital – Approximate cost: ₹10 lakhs

Since you have a ₹50 lakh cover, you confidently opt for the Five-Star hospital, believing your insurance will take care of the expenses. You get admitted, undergo treatment, and submit a claim, expecting a full settlement. But when the claim result arrives, it is shocking. Instead of ₹10 lakhs, the insurance company approves only ₹5 lakhs. The reason? ‘Reasonable and Customary Charges Clause.’

If you think this is just a hypothetical situation, think again. Thousands of policyholders face similar experiences daily, including Ahmedabad’s Brijesh Kumar. Brijesh bought a family floater policy of ₹10 lakhs from a government-owned insurer, Oriental Insurance. When his wife required multiple surgeries, the hospital bill amounted to ₹1,60,000. Despite having ample coverage, the insurance company approved only ₹1,32,600, leaving him to cover nearly ₹30,000 from his pocket.

The Harsh Reality of Health Insurance Claims

Many agents and insurance companies focus on selling policies, making grand promises. But when it’s time to claim, support vanishes. During our research, we found countless videos recommending health insurance but hardly any that explain how to maximize claim approval chances or what to do if a claim is rejected.

So, we decided to dig deeper. Instead of rushing a video, we took our time and studied 100–150 real-life cases, interviewed policyholders, and even spoke to insurance companies. Our goal? To provide solutions that genuinely help people.

5 Common Reasons Why Health Insurance Claims Get Rejected (And How to Prevent It)

1. Reasonable and Customary Charges Clause

This clause allows insurance companies to cap payments based on the average treatment cost in your locality. Let’s say you undergo cataract surgery in Hyderabad, where the usual cost is ₹50,000. Even if your hospital charges ₹1 lakh, your claim will be limited to ₹50,000.

✅ Solution:

  • Choose a reputed insurance provider that prioritizes fair claims.
  • Avoid insurers known for partial claim settlements.
  • Read the policy document carefully and understand such clauses.

2. Hospitalization Not Required

Insurance companies often reject claims stating that treatment could have been done in OPD (Outpatient Department) instead of hospitalization. Recently, a Jaipur-based policyholder had a ₹70,000 claim for dengue treatment rejected because the insurer argued it could have been treated without admission.

✅ Solution:

  • If your doctor advises hospitalization, get a written statement confirming it is medically necessary.
  • Submit this letter along with your claim to avoid disputes.
  • If the insurer still denies the claim, escalate it to the Insurance Ombudsman.

3. Documentation Errors

Many claims fail due to incomplete or missing documents. The requirements for cashless claims and reimbursement claims differ. A rejected cashless claim can still be filed for reimbursement, but only if documentation is proper.

✅ Solution:

  • Ensure all required documents are submitted correctly.
  • If you buy insurance from PolicyBazaar, their dedicated claim settlement team can assist you.
  • Double-check doctor’s signatures and hospital records to avoid fraudulent discrepancies.

4. Non-Disclosure of Material Facts

Material facts are details that affect your premium, like smoking habits, pre-existing conditions, or lifestyle choices. If undisclosed, insurers can reject claims.

✅ Solution:

  • Be transparent when purchasing the policy.
  • Disclose existing health conditions, habits, or medical history.

5. Insurance Ombudsman – The Last Resort

Most policyholders don’t know about the Insurance Ombudsman, a government body that resolves disputes free of cost. Over 4 lakh cases have been settled through this channel.

✅ Solution:

  • If your claim is unfairly rejected, file a complaint with the Insurance Ombudsman.
  • Provide proper documentation and written proofs to strengthen your case.

Final Thoughts

Health insurance is essential, but understanding policy clauses is equally crucial. By making informed choices, choosing the right insurer, maintaining proper documentation, and knowing your rights, you can avoid unexpected financial burdens. If you’re planning to buy health insurance, don’t just look at premium costs—focus on claim settlement ratios and company reputation.

🔗 Explore the best insurance options by visiting PolicyBazaar via the link in the description.

If you found this article helpful, share it with your loved ones. Because when it comes to health insurance, knowledge isn’t just power—it’s financial security.

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