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Factors for rejection of travel insurance claims basis

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Factors for rejection of travel insurance claims

One of the primary reasons why many travellers choose not to buy a travel insurance policy is they believe that when there is a claim to be settled, most Insurance companies along with their Assistance TPA’s find reason not to pay the claim. This is not entirely true since there are genuine reasons why claims are not admitted by the insurer.

Some of the key reason for travel claims being rejected are as follows:

  • Pre Existing Condition : This is perhaps the primary reason for difference of opinion between the insurance company and the insured traveller as far as medical claims are concerned. A pre existing condition means any condition, ailment or injury or related condition(s) for which the insured had signs or symptoms, and / or were diagnosed, and / or received medical advice/ treatment, within 48 months prior to commencement of the first Policy issued by the Insurer. This means that if the insured is traveling abroad with a pre-existing condition and avails of any treatment abroad, the insurance company will not be liable for paying the claim. The insurance company normally goes by the guidance of the attending physician in the medical facility abroad while deciding whether a condition is pre existing or not. If the attending physician declares that the cause of the treatment is a pre existing condition carried by the insured, then the treatment costs will not be reimbursed under the policy. Many a time, the insured traveller does not clearly declare a pre existing medical condition to the insurance company in the application form or to the distribution partner and buys a travel insurance policy. At the time of treatment this comes up and since the medical treatment is related to a pre existing condition, the same will have to be borne by the insured. Hence it is extremely critical for the insured to be aware of this fact that all travel insurance policies exclude pre existing medical conditions and not blame the insurance company for an unpaid claim.
  • No Coverage for the insured’s loss under the travel policy : One of the key steps that every traveller must ensure is to go through all coverage options before choosing the most appropriate plan. This is where a website like https://eindiainsurance.com/ come in real handy. The traveller can enter a few key fields like age, travel dates and destination and get all possible options for travel insurance. After comparing all the plans, they should choose the one which is best suited to their requirements. After buying the plan, they should go through the detailed benefits of the plan to ensure they are aware of what is covered and what is not covered. If possible, it is advisable that the insured travel also goes through the policy terms and conditions (also referred to as policy wordings) to understand the benefit coverages in detail. Sometimes the insured traveller assumes that a particular coverage is available under their plan and files a claim only to get a revert from the insurance company that the particular cover is not available. This could lead to a sore point between the insurer and insured. Let us look at three examples below:
  • Baggage Delay under Student Plan – most student insurance policies do not cover Baggage Delay but cover Baggage Loss. A student whose baggage gets unexpectedly delayed by the airline could make an assumption that since Baggage Loss is covered, Baggage Delay will also be covered and file a claim. This will not be paid. The Baggage Delay coverage should be explicitly stated on the policy.
  • Trip Cancellation Cover – Many times, insured make an assumption that a Trip Cancellation coverage ensures they can file a claim if their trip gets cancelled for any reason. This is however not the case. The reasons for Trip Cancellation are clearly stated in the policy terms andconditions (hospitalisation, sickness, injury, death to an immediate family member/insured) and if neither of these situations occur, the insured cannot file a Trip Cancellation claim and expect to be compensated.
  • Baggage Delay (Return to India) – Another important coverage understanding. Most travellers assume that since Baggage Delay is a cover under the policy, they can file a claim if there is a Baggage Delay on either their onward or return journeys. But many travel insurance policies do not cover Baggage Delay on their return journey (when the insured is returning to India) and hence such a claim will be rejected. This again is part of the terms and conditions of the insurer. The traveller should be aware of this cover and know that such a claim will not be entertained.
  • Lack of Sufficient Documentation for Expenses : One of the important concepts of insurance that all travellers should remember is that insurance is to make good a financial loss incurred by the insured on account of a peril/benefit/coverage under the policy. Hence if there is a loss occurred by the insured, the onus to support their claim of the loss is also with them and this is by submitting relevant proof of the same. If on account of a Baggage Delay for more than the deductible period, if the insured has incurred expenses on clothes/toiletries/accessories etc, they need to provide proof (bills relating to these expenses) as supporting documents for the claim. If they file a claim under any section of the policy, but are unable to provide supporting documentation for their expenses relating to this section, the insurance company in all fairness will deny the claim. Hence it is important for the insured traveller to retain original bills for expenses incurred relating to similar sections under the policy like Baggage Loss, Passport Loss, Flight Delay etc
  • No Approval for Medical Treatment / Routine Medical Tests exclusion : Another common reason for a rejection of claim is the lack of approval from the insurance company prior to seeking medical treatment, or seeking a reimbursement for a medical expense not incurred under the policy. Take the example of routine medical test like Blood Pressure Monitoring or Blood Sugar Testing. If these tests are conducted by the attending doctors/physicians as part of recommended treatment, then these expenses will be covered under the policy. However if the insured just chooses to visit a hospital and do these tests randomly just to check their BP/Blood Sugar levels, the expenses related to such tests will not be covered.
  • Delay in Reporting Claims : It must be noted that it is the duty of the insured to report a claim to the insurance company/Assistance TPA in a timely manner. There are occasions when the insured undergoes treatment at a medical facility/hospital citing insurance coverage and does not inform the insurance company. This results in the expenses being undertaken by the insured not being monitored by the insurance company and this could result in significantly higher medical bills at the end of the treatment. Sometimes the insured also pays for the treatment, carries the bills back to India and informs the insurance company 1-2 years after returning. This also will result in the insurance company needing to verify these documents with the hospital after a delayed period and paying a claim, they had not provided for in their books. Hence it is important for the insured to report a claim either on the Toll Free numbers or through email in a timely manner.

What are the primary reasons for the rejection of overseas mediclaim claims?

Claims are frequently denied due to insufficient documentation, failure to inform the insurer within the designated timeframe, treatment for conditions that are excluded, or misrepresentation of medical history.


Will my claim be denied if I obtain treatment without prior approval from the insurer?

Yes, for non-emergency procedures, many insurers mandate pre-authorization. If you bypass this requirement, your claim may be rejected unless you can provide a valid reason for the urgency.


Can the non-disclosure of a previous illness result in rejection even if it is not related to my current claim?

Yes. Insurers may deny claims if they discover that you concealed important health information when purchasing the policy—even if the claim pertains to a different matter.


What occurs if I neglect to bring my policy documents while traveling?

While digital versions are generally acceptable, not providing policy information during an emergency can delay or obstruct the processing of claims.


Is reimbursement for self-treatment or over-the-counter medications permitted under overseas mediclaim?

No. Claims for self-medication or treatments that are not prescribed are usually not reimbursed.


Can a travel insurance claim be denied due to alcohol consumption?

Yes. If the incident or medical issue arose while under the influence of alcohol or drugs, the insurer has the right to reject the claim.


Is it permissible to claim after returning to India?

Certain policies permit claims after returning within a designated period (for instance, 30 days). However, all invoices and documents must be submitted without delay, as any postponement may lead to denial.


Will I be reimbursed if I opt for a non-network hospital overseas?

Yes, reimbursement is possible, but only if the treatment qualifies under the policy. You will be required to pay upfront and submit all original invoices and medical documentation for reimbursement. Cashless services are typically restricted to network hospitals.


Can claims be denied for minor or outpatient treatments?

Certain policies may impose a minimum claim threshold or may not cover outpatient (OPD) treatments unless they arise from a medical emergency.


What steps should I take to prevent claim denial?

  • Thoroughly review the policy's inclusions and exclusions
  • Honestly declare all pre-existing conditions
  • Retain copies of all relevant documents (invoices, prescriptions, discharge summaries)
  • Notify the insurer promptly in the event of hospitalization
  • Obtain prior approval for any planned treatments.

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