Shocking Truth About Health Insurance Claims You Must Know (2025 Guide)

Buying health insurance feels like a safe step — but the real shock comes when your claim is rejected or delayed. Every year, thousands of policyholders in India discover harsh truths about the claim process. At ClaimWeb, we’ve studied hundreds of real-life cases to uncover what insurers don’t tell you upfront. Here’s the truth you must know before it’s too late.

1. Why So Many Health Insurance Claims Get Rejected

Claim rejection is not always about fraud — sometimes, it’s about missing details or unclear documents. According to the IRDAI 2024 Claim Ratio Report, nearly 7 out of 100 health insurance claims are either rejected or delayed every year.

Non-disclosure of Pre-existing Diseases: Not informing the insurer about diabetes, BP, or past surgeries can result in claim rejection.
Incorrect Documentation: Missing discharge summaries, unclear invoices, or mismatched diagnosis details lead to rejection.
Policy Waiting Period: Many policies have a 2–4 year waiting period for specific illnesses. Claims filed before that time are denied.

ClaimWeb Tip: Always read the “Exclusions” section carefully before signing your policy. Over 60% of rejected claims fall under hidden exclusions.

2. The Myth of Cashless Claims

“Cashless claim” sounds simple, but in reality, it’s not 100% cashless. Hospitals often charge for non-medical or consumable items such as gloves, room upgrades, and service charges. These are usually not covered by any insurer.

Even after approval, insurers may partially settle the amount. Always ask your hospital for a breakdown of covered and non-covered charges before admission.

Learn more about this in our guide on No Claim Bonus in Health Insurance.

3. The Hidden Delays That Cost You Dearly

Delays are one of the most common frustrations faced by policyholders. According to ClaimWeb’s internal data, 1 in 4 claims gets delayed due to incomplete paperwork or missing timelines.

Common Reasons for Claim Delays:

Submission of claim forms after the 30-day limit
Hospital not sending final bills to insurer on time
Query raised by insurer not answered by the patient or family

Pro Tip: Always track your claim on the insurer’s online portal. If it’s pending beyond 15 days, raise a complaint to IRDAI through their Bima Bharosa Portal.

4. Pre-Existing Diseases Can Make or Break Your Claim

This is the biggest hidden factor behind claim troubles. If you had an illness before taking the policy and didn’t disclose it — even unintentionally — your claim may be permanently void.

Read our full article: Pre-Existing Diseases in Health Insurance — What You Must Know Before Buying.

Most insurers conduct pre-policy health check-ups, but they rarely highlight that any later-discovered condition may be counted as a “non-disclosure.” That’s why honesty at the proposal stage is key.

5. The Fine Print That Nobody Reads

Policy documents are full of medical and legal terms — and that’s where most traps hide. Some examples include:

“Reasonable and Customary Charges” — insurer pays only what’s considered standard for that city, not necessarily your full bill.
“Day Care Treatments” — only specific short-duration procedures are covered, not all OPD visits.
“Co-payment Clause” — you must bear a percentage of the claim amount, especially after 60 years of age.

ClaimWeb Insight: Always download and keep the policy wordings PDF from the insurer’s website. Compare it with competitors using IRDAI’s Health Insurance Comparison Tool.

6. The Role of Network Hospitals

Many policyholders don’t realize that treatment at a non-network hospital may lead to reimbursement only — not cashless claims. Always check the insurer’s network hospital list before choosing where to get admitted.

For best results, stick to empanelled hospitals. They handle documentation faster and are directly connected to the insurer’s TPA (Third Party Administrator).

7. Common Mistakes Policyholders Make

Not informing the insurer within 24 hours of hospitalization
Submitting bills without a covering letter
Not cross-verifying doctor’s diagnosis with policy terms
Claiming under the wrong section (cashless vs reimbursement)

One real example: A ClaimWeb user from Mumbai lost ₹1.8 lakh because the hospital mentioned “gastritis” while the insurer classified it under “pre-existing digestive condition.” Always ensure diagnosis codes match your claim paperwork.

8. How to File a Perfect Claim (Step-by-Step)

Inform the insurer/TPA immediately after hospitalization.
Submit pre-authorization form for cashless approval.
Keep all invoices, test reports, and prescriptions organized.
Ensure hospital stamp and doctor signature on each page.
Follow up through call or portal until claim is settled.

9. What to Do If Your Claim Is Rejected

If your claim is denied, don’t panic. You can raise a formal complaint through the insurer’s grievance cell. If not resolved within 30 days, escalate to:

IRDAI Bima Bharosa Portal
Insurance Ombudsman Office (for regional disputes)
Consumer Court (in extreme cases)

ClaimWeb Reminder: Always keep written communication of every conversation with the insurer — even emails count as proof.

10. Final Words — The Truth Revealed

The truth about health insurance claims is simple yet harsh: insurance works only when you understand it deeply. The process is not designed to cheat you — but ignorance can cost you lakhs. Educate yourself, ask questions, and never sign a policy without reading every page.

At ClaimWeb, we believe every Indian deserves a transparent and fair claim process. Stay informed, share this article, and help others avoid costly mistakes.

Frequently Asked Questions (FAQs)

1. What is the main reason for health insurance claim rejection?

The top reasons include non-disclosure of pre-existing diseases, missing documents, and waiting period violations.

2. How long does a health insurance claim take to settle?

Most insurers settle within 15–30 days if all documents are submitted correctly.

3. Can I reapply after a claim rejection?

Yes. If you can prove that the rejection was due to an error or missing information, you can appeal through the insurer’s grievance cell or IRDAI portal.

4. Are consumable items covered under health insurance?

No. Items like gloves, masks, and room service charges are generally excluded unless your policy specifically mentions them.

5. What should I do if my insurer delays claim settlement?

Contact the insurer first, then escalate to IRDAI or Insurance Ombudsman if it exceeds 30 days without valid reason.