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Insurance Claim Rejected, Here Are 10 Insurance Company Claim Rejection Reasons

Insurance company not paying claim? Here are the reasons for the rejection of your insurance claim you should to know.

Overview #

The difficulty of managing insurance claims is often a scourge for insurance policyholders. Not a few also make this one of the reluctance to buy an insurance policy, be it health insurance, car insurance, or travel insurance. However, the difficulty of processing these claims is not without reason. Everything is in the agreement between the insurer and the buyer of the insurance policy and is legally bound. This means claims will not be carelessly rejected.

Here are the reasons for the rejection of your insurance claim:

Insurance Company Claim Rejection Reasons No.1

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The policy is Inactive (Lapse) #

Insurance Company Claim Rejection Reasons - insurancewhat.com
Policy is currently inactive

Insurance policies can be in an inactive state due to several circumstances. This inactive state is also known as a lapse. The insurer is not willing to pay insurance claims when the policy is in lapse. Here are two examples of situations where the policy is being lapsed and your insurance claim is rejected.

  • Payment of insurance premiums is due because it has passed the grace period. Each insurance may have a grace period that is different. Usually a maximum of about 45 days. If the incident occurs after that period, the insurance will not be responsible for any losses suffered by the policyholder, even if it is included in the policy clause. Pay the insurance premium on time or at least not until the end of the grace period.
  • If the insurance policy is in the form of a unit link, the policy can be considered a lapse if the cash value of the insurance is not sufficient to cover the cost of insurance. There are at least two reasons for this insufficient cash value, namely poor investment performance and frequent cash disbursements. To avoid this, it is better to do a top-up at a certain time when the investment performance is poor. In addition, make sure not to cash out the value, unless you are in a state of urgency at any time.

Insurance Company Claim Rejection Reasons No.2

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Claims Not Covered by a Clause #

Insurance Company Claim Rejection Reasons
Insurance Company Claim Rejection Reasons

The insurance policy contains an agreement that includes the criteria for what is and is not covered by insurance. In TLO car insurance, what is meant by serious damage can vary from one insurance to another. It could be at least 70%, 75%, even 80%. Thus, insurance will not cover damage financing, if the damage does not reach the agreed percentage.

We take another example. For example, the policy states that a stroke is a cerebral-vascular attack, permanent neurological, in more than 24 hours. Even if a doctor diagnoses a policyholder with a stroke, but it is still less than 24 hours, an insurance claim cannot be filed because it will definitely be rejected.

Insurance Company Claim Rejection Reasons No.3

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Submission of Claims Beyond the Allotted Time #

Insurance Company Claim Rejection Reasons
Submission of Claims Beyond the Allotted Time

Insurance claims can be delayed or even rejected if the claim processing exceeds the time specified in the policy. Insurance always provides a certain time limit for processing claims. Through that, the claim can be rejected. Car insurance claims must be taken care of immediately because the time limit is short, only 3 x 24 hours. Meanwhile, for insurance such as life insurance, the time limit is between 30-60 days.

Insurance Company Claim Rejection Reasons No.4

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Incomplete Claim Documents #

Insurance Company Claim Rejection Reasons
Incomplete Claim Documents

Make sure you know all the documents that must be provided when you want to submit a claim. One missing document, the insurance will reject the claim. For example, for life insurance, a certificate from a doctor is required. You are also required to fill out a claim form.

Follow the procedure properly. If the claim submitted is a car insurance claim, be sure to take photos of the car damage. This photo will be one of the proofs when you want to submit a claim to insurance.

Next, prepare complete documents, starting from a photocopy of the insurance policy, a copy of the driving license and vehicle registration certificate, and of course the claim submission form. A police certificate may also be required in the event of serious damage.

When filling out the form, fill it honestly and clearly because the insurance company will check it later. They will not pay a claim if the claim form is proven to contain lies.

Another procedure that is no less important is making repairs at partner workshops. The same thing also includes going to a hospital that is referred to by insurance. Not allowed to repair or seek treatment in a place outside of the insurance referral.

Read Also

Insurance Company Claim Rejection Reasons No.5

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Being in the Waiting Period #

Insurance Company Claim Rejection Reasons
Status Is On A Waiting Period

In certain types of insurance, there is usually a policy called a waiting period. Insurance policy buyers will not be able to submit claims if they are in the waiting period. For the critically ill, there will usually be a waiting period of around 30 to 365 days.

Say the waiting period is around 30 days. The insurance policy was purchased on April 14, 2021. Then he became critically ill on May 14, 2021. If he made a claim, the insurance would reject him, because he had not passed the waiting period.

Insurance Company Claim Rejection Reasons No.6

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Disease Preexisting Before Policy Purchased #

Insurance Company Claim Rejection Reasons
Disease Preexisting Before Policy Purchased

Policy owners will also be denied claims if they hide their illness when purchasing a claim. Even if the waiting period has passed, if it is proven that the disease has actually been experienced since before purchasing the policy, the insurance will reject the claim. So, make sure you are still in good health when buying insurance.

Insurance Company Claim Rejection Reasons No.7

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Submission Claims Including Exceptions #

Insurance Company Claim Rejection Reasons
Submission claims are exempt

In addition to regulating matters that include insurance coverage, the policy also regulates exemptions. These exceptions are things that are not covered by insurance. In life insurance, these exceptions include death by suicide, court punishment, or crime.

For car insurance, the exceptions that make a claim rejected include vehicles that are not functional or modified without notifying the insurer. An example of a vehicle that is not functioning according to its designation is using a motorbike to transport goods that exceed its capacity.

As for the case of motorized vehicle modifications, make sure you always notify the insurance and make sure that modifications are allowed. Do not let non-standard modifications be the cause of the accident. If this is the case, the insurance will not be willing to cover the cost of repairs.

Insurance Company Claim Rejection Reasons No.8

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Policyholders violate the law #

Insurance Company Claim Rejection Reasons
Policyholders violate the law

Another reason that an insurance claim is rejected is if the policyholder commits an act against the law. For example, if he has all-risk car insurance and then his car has an accident due to recklessness or traffic violations, he cannot file a claim. The same is true if the policyholder does not have a driver’s license when driving, parking anywhere, and getting drunk.

A health insurance policyholder will also not be able to file a claim if, for example, he is seriously injured as a result of being beaten by a mob while committing a crime. The insurance policy is always compliant with applicable laws, so it is impossible to accommodate things that occur because of violations of the law.

Insurance Company Claim Rejection Reasons No.9

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Committing an insurance crime #

Insurance Company Claim Rejection Reasons
Committing an insurance crime

What is meant by insurance crime is an act of lying or sabotage that is deliberately committed by the policy owner or his heirs so that the insurance claim is paid. An insurance policy owner may injure himself, burn his own house, or intentionally cause an accident to get compensation from insurance.

The insurer will automatically reject the claim if after investigation it is found that the action was intentional. The same is true if an heir commits a crime against the policy owner in order to get a claim from insurance.

Insurance Company Claim Rejection Reasons No.10

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Event Area Not Included in Insurance Services #

Insurance Company Claim Rejection Reasons
Event Area Not Included in Insurance Services

Insurance policies may also include clauses regarding territories in the agreement. Claims are only served when the incident occurs in a certain area. If a person has insurance for his life in Indonesia and the policy states that a claim can only be filed if he dies in Indonesia, it means that the claim will be rejected if he goes abroad for treatment and dies there.

Insurance Company Claim Rejection Reasons No.11

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Limit Has Exceeded #

Insurance Company Claim Rejection Reasons
Limit has been exceeded

Everyone agrees that the customer is king. Even so, each customer cannot arbitrarily make their own decisions, because customers must also follow the rules or regulations that have been applied to financial institutions, including insurance.

Each insurance company determines the maximum claim value that can be realized. If customers frequently make claims, the limit will run out. For subsequent claims, the insurance company will refuse.

Insurance Company Claim Rejection Reasons No.12

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The company does not guarantee insurance anymore #

Insurance Company Claim Rejection Reasons
The company does not guarantee insurance anymore

Each company collaborates with insurance to serve as a permanent employee benefit. This insurance is valid as long as the employee works at the company. When the employee has resigned from the company, the employee can no longer claim the insurance previously provided by the company.

Insurance Company Claim Rejection Reasons No.13

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Claims outside the specified list of partners #

Insurance Company Claim Rejection Reasons
Claims outside the specified list

If you make a cashless claim on insurance, then you cannot claim the insurance outside the predetermined list of partners. You can only claim insurance at partners who have collaborated with the insurance you choose.

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The Conclusion #

Pay close attention

There are many reasons for rejection of your insurance claim and one of the best ways to find out is to examine, study, and understand the contents of the policy. Many policyholders ignore this and end up losing money because of their own mistakes.

Every policy owner must pay close attention to any circumstances that make his claim approved or not. Every definition and explanation in the clause must be understood correctly. It takes time to understand it because the language used is a legal language that is difficult for the average person to understand. However, learning this will go a long way when he needs to file a claim later.

Make sure to avoid things where the claim is rejected. If you feel dissatisfied with the reason for the rejection of the insurance company, there is a special agency that deals with cases of disputes like this. Policy owners can take the case to court.

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By Matt Adam

Administrator and Author

Matt Adam is the founder and administrator of InsuranceWhat.com, the insurance best resources site. Learn more about him here and connect with him on the...