Common reasons why health insurance claims get rejected

Health insurance broker, Bloom, offers top-quality and affordable medical insurance plans for South Africans. Momentum Health4Me is designed to provide access to private healthcare facilities and practitioners. However, many people become despondent when their health insurance claims are rejected. Bloom assures you that this problem can often be resolved by being more aware of the process and procedures involved when making a health insurance claim. Find out what you need to do to avoid a rejected claim.

Top reasons for health insurance claim rejection

1. Incorrect information provided. The most common mistake that claimants make is submitting information that doesn’t match the details captured in the database. This could include your name, identity number, policy number or date of birth.

2. Policy lapse. If you have allowed your policy to lapse and have not renewed it within the due date, or if you have fallen into payment arrears, you will forfeit the policy benefits as the policy would have been suspended or cancelled by the insurer.

3. Stale claim. There is a time limit to submit a health insurance claim, which is 120 days from the date of treatment. If you’ve been hospitalised for an emergency event, like a heart attack or car crash, you need to inform your insurer within 48 hours in order to qualify for the major medical events benefit.

4. Failure to gain approval or a referral. This refers to an out of network consultation where a member went to a medical specialist without first getting a referral letter from a GP. It can also mean that a member went to a GP who was not part of the Momentum CareCross Network.

5. Claiming within a waiting period. Many health insurance benefits have waiting periods of three to six months before a member is entitled to claim. This means you cannot claim before that period ends.

6. Claiming for an exclusion. There are exclusions in health insurance policies. This relates to a period of time that must pass before your health insurance comes into effect. Before that period, you cannot claim as you are not covered for that specific benefit.

7. Hospitalisation done by the member. A Health4Me member can only be hospitalised in the event of an accident or an emergency, like a heart attack or stroke. It could also mean that the illness in hospital was not covered or that the member did not have major medical events benefits.

8. Claiming for a procedure or ICD 10 code not covered. While Health4Me does cover some minor medical procedures, it must be noted that not all procedures are covered. A procedure conducted in a GPs room may not be covered as per the code of listed procedures. Likewise, while health insurance does cover pathology and radiology, this will not be covered if it is not under the listed ICD10 codes covered by Momentum Health4Me.

9. Claiming for benefits exceeded. This means that Health4Me has paid up the maximum limit for which cover is provided and that the member is now responsible for the remaining balance owing.

Points to be aware of when submitting a health insurance claim

What are waiting periods?

Contrary to some misconceptions, not all benefits on health insurance options come into effect from the day the policyholder is insured. Instead, there are waiting periods in place for certain benefits. A waiting period is the amount of time that needs to pass before your health insurance benefit comes into effect.

For instance, there is a three-month waiting period that applies for the day-to-day Optometry Benefit that is available for members on the Health4Me Gold and Health4Me Silver plans. Waiting periods will differ from benefit to benefit with some waiting periods stipulating that members complete a full 30-90 day cycle before the health insurance benefit comes into effect. Medical expenses incurred before the waiting period has ended will not be covered by Health4Me.

The most common health insurance exclusions

A health insurance exclusion relates to the conditions that are excluded from your health insurance plan, which means you will not be covered. For instance, Dentistry Benefits are only available to members of the Health4Me Gold and Health4Me Silver health insurance plans. Those members on the Health4Me Bronze plans are excluded. Sometimes, there are exclusions for certain types of health conditions or services such as:

Certain types of medication not found on the Health4Me formulary
Alternative health therapies, like homoeopathy, acupuncture, yoga or meditation
Cosmetic or aesthetic surgery, like breast enlargement surgery
Injuries sustained intentionally or as a result of illegal activity
Injuries sustained while under the influence of alcohol or banned narcotic substances
Certain types of congenital disorders, like a hearing impairment
Some types of treatment for mental health conditions. For instance, Health4Me will cover a specialist psychiatrist consultation but not a psychologist or group therapy.

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Obtaining a referral, pre-authorisation or approval

Pre-authorisation, or pre-approval, is a process that must be followed in order to obtain access to certain medical services and in order to submit a successful health insurance claim. You need to gain pre-authorisation in order to apply for chronic medication benefits or to access in-hospital treatment, and you need a referral letter from your GP in order to visit a specialist. For hospital authorisation, the member should call Netcare directly for an ambulance and authorisation at 082 911.

How to submit a health insurance claim properly

1. Check your information thoroughly. Proofread and double-check that you’ve inputted the correct information.

2. Submit within the time period. The health insurance claim period is 120 days before it’s considered a stale claim by your insurer.

3. Read your policy. Be aware of your exclusions, waiting periods and benefit limits. If you’re unsure, speak to your broker.

4. Gain the necessary referrals, approvals and pre-authorisations in advance and keep the documentation or codes you receive as proof thereof.

5. Keep your policy updated and keep up to date with your payments.

Your health insurance claim process made easy with Bloom

Bloom is committed to service excellence. Submit a successful health insurance claim by following our easy tips about what you should do to avoid rejection. Get comprehensive health insurance cover for your whole family. Contact our offices to make an appointment with a trained consultant who can provide detailed information about your affordable health insurance options.

Medical Content Disclaimer

You understand and acknowledge that all users of the Bloom website are responsible for their own medical care, treatment, and oversight. All content provided on the website, is for informational purposes only and does not constitute medical advice. Neither is it intended to be a substitute for an independent professional medical opinion, judgement, diagnosis or treatment.

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Momentum Health4Me is not a medical scheme product, and is not a substitute for medical scheme membership. The information provided on this website does not constitute advice in terms of the Financial Advisory and Intermediary Services Act. Momentum is a division of Momentum Metropolitan Life Limited, an authorised financial services provider (FSP 6406) and a wholly owned subsidiary of Momentum Metropolitan Holdings Limited.

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© Bloom Financial Services 2023. Bloom Financial Services (Pty) Ltd is an authorised financial services provider (FSP 50140). Bloom Gap is underwritten by Infiniti Insurance Limited a licensed non-life insurer and an authorised financial services provider (FSP No.35914)

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