Non-submission of the query reply is a condition in group health insurance under which a claim can be rejected. This can occur due to late or incomplete submission of the required documents for the claim process. If the policyThe legal document issued to the policyholder that outlines the conditions and terms of the insurance; also called the ‘policy is administered by a third-party administrator (TPA), reminders to submit documents are sent from the TPA to the insured person. If the claimant does not respond to the query or fails to submit the document on time, the insurance company can reject the claim due to non-submission of the query reply.
Why is a claim rejected due to non-submission of the query reply?
To process the claim further under group health insurance, it is mandatory to submit all original documents. This applies to both cashless and reimbursement cases. If the required documents are not provided within the specified time period, the claim will be rejected according to the checklist.
Can a claim be rejected due to non-submission of the query reply?
Yes, a claim can be rejected due to non-submission of the query reply under certain conditions, such as:
- Claim Form: Filling out a claim form is necessary to get any claim, as per IRDA regulations. The form must be attached with all required original documents, bills, reports, prescriptions, along with the treating doctor’s signature and hospital stamp. If an insured person fails to submit the claim form after being asked for it by the insurance company, the claim will get rejected due to non-submission of the query reply.
- Discharge Summary: The discharge summary, signed by the treating doctor and stamped by the hospital, must also be included in the attachments when filing for a claim. If the insured person has not submitted the discharge summary, a query is raised from the TPA/insurer reminding them to send the required document. Even after several reminders, if the insured person fails to submit the document, the further process of the claim is rejected due to non-submission of the query reply.
- Final Bill with Breakup: The final bill, which can be generated by requesting the treating doctor to provide a tentative breakup of the hospital bill, is a mandatory document for the claim process. Without this document, the insurer cannot finalise the amount the company will pay. If an insured person does not respond to the query and fails to submit the document, the claim will get rejected due to non-submission of the query reply.
- Payment Receipts: The payment receipt or cash paid receipt is a mandatory document that serves as proof of the amount paid for a service or item. Without this document, a claim cannot be processed, and if an employee does not submit the claim form after being asked by the insurance company, the claim will get rejected due to non-submission of the query reply.
- Supportive or Positive Investigation Reports: Positive investigation reports are medical test reports, such as MRI, X-rays, and angiograms, that confirm a disease, diagnosis, or illness of the patient. The patient needs to be hospitalised with an active line of treatment. If the insurance company does not receive this document, the claim will not be further processed, and if they do not receive a response on the query, they can reject the claim due to non-submission of the query reply.
- Original Bills: All original bills are required for a claim to be processed. If an insured person does not submit the original bills, the insurance company can reject the claim due to non-submission of the query reply.
- ICP Papers: While ICP papers are not mandatory, the insurance company has the right to ask for any medical documents required for the claim justification. If the insured person fails to provide the ICP papers when requested, the insurance company can reject the claim due to non-submission of the query reply.
In summary, there are several reasons why a claim can be rejected under group health insurance, and non-submission of the query reply is one of them.
To avoid such conditions, proper guidance and assistance from PlanCover can be helpful. The claim process can be tedious and time-consuming, but with the right support, it can be resolved efficiently.
