Beware: Errors in Medical Records Could Complicate Your Health Insurance Claim

A small error in your medical records may sometimes create serious complications while filing a health insurance claim. Policyholders are therefore advised to carefully check important details in hospital records, discharge summaries and other documents submitted to insurers.

For example, imagine a person who was healthy when purchasing a health insurance policy but developed high blood pressure eight months later. If a medical document mistakenly records that the person had been suffering from the condition for “eight years” instead of “eight months”, the discrepancy could raise questions during the claim assessment.

Such errors do not automatically mean that a claim will be rejected. However, major inconsistencies or incorrect information that affect the insurer`s assessment of the claim, policy coverage or pre-existing medical conditions could result in additional scrutiny and delays. In some cases, they may contribute to a claim dispute or rejection.

The Insurance Regulatory and Development Authority of India (IRDAI) states that insurers must process claims according to the terms and conditions of the policy. If a claim is rejected, the insurer is required to communicate the reasons for the rejection and refer to the relevant policy conditions.

Therefore, policyholders should not blindly submit medical documents without reviewing them.

What should you check?

Before submitting a health insurance claim, carefully verify:

- The date of diagnosis and duration of the illness

- Medical history and pre-existing conditions

- Dates of admission and discharge

- Name, age and other patient details

- Diagnosis and treatment information

- Discharge summary and doctor`s notes

- Any obvious spelling, typing or factual errors

If you notice an important mistake, request the hospital or treating doctor to review and correct the record, wherever appropriate, before submitting it to the insurance company.

If your claim is rejected and you believe the decision is unfair, you can first approach the insurer`s grievance redressal mechanism. If the issue remains unresolved, you may escalate the matter through IRDAI`s grievance system or, where applicable, approach the Insurance Ombudsman.

Bottom Line

A simple typo will not necessarily cause your entire health insurance claim to be rejected. But inaccurate or contradictory information in medical documents can create avoidable complications. Taking a few minutes to review important records before submitting a claim could help prevent unnecessary delays and disputes.

This article is intended for general awareness and should not be treated as legal or insurance advice.