Having a health insurance plan such as the Medicare Advantage Plans 2021 is more of a milestone than an accomplishment because with it comes, varied medical benefits such as free vaccines, free preventive care, screenings, and checkups and that is before you are presented with the deductibles. However, there comes a time when your healthinsurer might reject your claim, with reasons best known to them but which you should also be aware of to avoid the mistakes. 

So some of the basic things that will lead to your insurer rejecting your claim is providing false information about your age, income, and occupation. Other grounds that might also lead to your health insurance being rejected are a lapse in policy, failure to appoint or update nominee details, and avoiding medical tests among others. 

Once your health insurance claim gets rejected there are a few things that you can do to help salvage the situation, check below. 

Health insurance is a contract between two parties and involves the exchange of money for services meaning that it is subject to a legal process in case of a dispute.  On your part it is, therefore, your duty to first research the insurance companies that are notorious when it comes to claims denial; some of which are Conseco, Liberty Claim, AIG, and WellPoint among others. 

And on the same note, we have the health insurance companies that pay claims with ease some of which are the Blue Cross or Blue shield which has been determined to be the best for nationwide coverage, we also have United Healthcare Services Inc, Humana, and Kaiser Foundation Health plans among others. 

What to do when your insuranceclaim gets rejected

  • So the first logical thing to do is to gather compelling evidence which of course supports your claim or one which will undermine the understanding that your insurer is using as a basis to deny you your claim. 
  • The second step is that you will need to make a formal complaint in writing addressed to your Insurer’s Internal Dispute Resolution Department. If you don’t get any help in the above process, the only remaining option is to take your insurance company to court. 
  • But first, you will lodge a complaint with the AFCA but only if your insurance company is a member of the AFCA and if you have already complained to the Internal Dispute Resolution department. 
  • Now the problem with AFCA is that it doesn’t sit on all types of disputes, but will gladly deliberate on matters where the claim is for $500,000 or less. AFCA also has the authority to decide on whether the claim should be paid, the calculated amount, or whether the complainant should be paid interest due to unreasonable delay in payment. 

Other options 

If you know that are on the wrong as regards the denied claims then you just have to accept the outcome without challenging it. You will also reach out to your insurer and find out the relevant internal and external dispute resolution process. In essence therefore is that you will first try the internal dispute resolution process before opting for the external. 

Most importantly is to get information from the insurer why your claim was rejected, you will then have to address the reasons that the insurance has laid bare before you proceed to the AFCA. And as you seek to have your claim accepted, it is important to keep an open mind and see reason, which then means that the rejection of the claims might be overturned and you get to receive the claim. 

The insurer may also give reasonable grounds on why they rejected the claim with which you will have no choice but to accept. 


Apart from having a roof over your head, good health is paramount, so before signing your health insurance contract, ensure that you have the correct information with you. State your correct age, give true information about your occupation and income, remember that age is used to define risk, so if you lie about this, it might get rejected in the future. 

Lastly, for one to successfully dispute a claim decisionthey must have evidence and this, therefore, calls for you to be very accurate in keeping records. Don’t try to negotiate without evidence because more times than not your memory will fail you.