What are the reasons for insurance denials?

There are two most common reasons for insurance denials: failure to tell the truth when buying insurance and failure to comply with the insurance coverage liability clause after the accident. What you need to know about insurance claims is: How much do you know about insurance claims?

Insurance companies will not easily make the decision to refuse claims, after all, in our country, insurance companies are strictly supervised by the China Banking and Insurance Regulatory Commission. Once the compensation is unreasonably refused, not only will the reputation be damaged, but also the punishment from the CBIRC.

1.Whether the accident is covered by the insurance, or whether it is within the scope of the exclusion of liability

Insurance is essentially a paper contract between us and the insurance company, and the provisions of the contract are the final basis for the settlement of claims.

Therefore, when applying for insurance, you must carefully read the insurance terms and conditions, and clarify the content of the insurance, liability exemption, etc., so as not to cause disputes in the later stage.

2.The health notice is not truthful

When buying health or longevity insurance products, remember to tell us truthfully about your health status. Many people fill in the smart underwriting casually, and finally regret it when they don't meet the conditions and are denied.

3.The claim materials are not fully prepared

Incomplete preparation of claim materials often affects the speed of the insurance company's investigation of the case, thereby affecting the timeliness of the claim. Therefore, the materials for the claim must be prepared.

4.If you are unable to obtain a claim, please report to the regulatory authority or go through litigation

When a dispute arises in the settlement of a claim and both parties feel that they are in charge, the consumer can report it to the regulatory authority or use the law to protect his rights and interests.

Claims are not settled by the insurance company, everything must be based on the terms of the contract, as long as the consumer meets the conditions of the insurance clause, the legal and regulatory authorities will protect the rights and interests of the consumer.

An important reason why the insurance company does not pay is that it does not meet the requirements of the terms. The insurance company will only pay if it fully complies with the description of the clause.

Generally speaking, insurance companies will not refuse to pay. The insurance company will refuse to pay only if the insured has concealed the health notice, the insured has taken out the insurance for reasons mentioned in the exclusion clause, the insurance has occurred during the waiting period, the insurance company has not met the claim conditions, and the claim information is incomplete.

If you do encounter an insurance company's rejection, don't panic. Senior Sister has prepared a guide for you, click the link below to receive it for free: the correct operation process in case of claim disputes.

Next, the senior sister will talk to you about how we should reduce the situation of insurance company refusal. First of all, we must achieve the principle of maximum integrity in health notification, and we will answer what others ask. Do not conceal your illness in order to pass the health notice, otherwise it will be easy to be rejected by the insurance company in the process of subsequent claims.

In addition, when we buy insurance, we should give priority to purchasing insurance with a relatively short waiting period. The so-called waiting period is a period of time set by the insurance company in order to prevent the insured from cheating the insurance, and if the insurance is insured during the waiting period, the insurance company will not be liable for the claim. Therefore, for the insured, the shorter the waiting period, the sooner he can get the protection, which can increase the probability of compensation to a certain extent.

Most critical illness insurance plans on the market today have a waiting period of either 90 days or 180 days. We can purchase critical illness insurance with a waiting period of 90 days first.

Regarding the basic concept of the waiting period, the senior sister will talk about it first. So what should you do if you are really unfortunate enough to be out of danger during the waiting period? Senior sister has prepared a special strategy for this situation, if you need it, you can take a look at the following article:

During the waiting period, the insurance company will not pay? If you don't understand, you'll suffer a big loss!

The common reasons for insurance denial are not truthfully informed or not covered by insurance.

Learn more about this article.

1.Failure to truthfully inform about health

In the process of applying for insurance, it is necessary to go through the link of health notification.

Generally, certain inquiries are made about the health and occupational categories of the insured, in order to assess the risk status of the insured and whether he is eligible for insurance.

According to Article 16 of the Insurance Law, the insurance company has the right to terminate the contract if the health notification matters that have been clearly inquired about are not truthfully informed;

Even if something really happens, the insurance company has the right to refuse the claim, and the premium will not be refunded!

2.Not covered

Insurance has both coverage and exclusion of liability.

If any of the exclusions arise, or if there is a circumstance outside the scope of coverage, the insurance company will refuse to pay.

3.Accident during the waiting period

Health insurance generally has a waiting period, usually 90 days or 180 days, mainly to prevent illness.

If the insurance is taken out during the waiting period, the insurance company will refund the premium, but will not pay the sum insured.

The waiting period will vary depending on the type of insurance.

Critical illness insurance: Some are 90 days, some are 180 days, and even longer are 360 days. The shorter the waiting period for the customer, the better.

Life insurance: Generally in 90-180 days.

Medical insurance: Basically in 30-90 days.

Accident insuranceDue to the unpredictable nature of accidental injuries, there is generally no waiting period, but it should be noted that the effective date is that most accident insurance takes effect at 0:00 the next day, and some take effect a few days later.

If the insurance company refuses to make a claim, it does not mean that it can be accepted unconditionally, and you can also try the following ways:

NegotiationArticle 24 of the Insurance Law stipulates that an insurance company must explain the reasons for refusing to pay compensation. If there is a dispute among consumers, they can file a complaint or negotiate;

ComplaintsIf the negotiation fails, you can file a complaint with the CBIRC;

Arbitration: The arbitration committee invites insurance experts to deal with disputes, which can generally be resolved fairly and reasonably;

LitigationIf there is a serious disagreement between the parties on the claim, it can only be decided through court proceedings.

In short, claims are made in strict accordance with the terms of the insurance and the law, and you don't need to worry too much. In order to avoid unnecessary claims disputes, Daddy recommends that consumers should tell the truth when buying insurance, and also carefully read the insurance terms, especially the waiting period, protection responsibilities and exclusions, etc., so as to maximize their protection rights. Hope!

1.Pre-existing conditions are insured. Pre-existing conditions refer to the fact that the insured has physical problems before applying for insurance, which is what we often call applying for insurance with illness.

When investigating claims, insurance companies often judge whether the insured has pre-existing conditions based on records such as hospital visits and pharmacy prescriptions, and long-term chronic diseases such as kidney disease are the focus of the insurance company's investigation. 2.Not covered

Accident insurance policies do not provide protection for disease risks, such as sudden cardiac death and other diseases, which are common rejections of accident insurance. Some accident insurance also requires the annual income of the policyholder, and the insured amount cannot exceed 10 times the annual income, and the excess part of the premium will not be refunded without paying the insured amount. For critical illness insurance, it is often necessary for the disease to meet the claim criteria, such as cancer requiring pathological diagnosis, myocardial infarction requiring bypass, etc.

3.Preservation issues. For issues such as a change of address or change of beneficiary, the insurance company will not refuse to pay, but it is difficult to say otherwise.

Wrong age: If the insurance age is wrong due to personal reasons, and the actual age is not within the insurance requirements, the insurance company will refuse to terminate the claim. Occupation Type Change:

Many accident insurance and critical illness insurance have strict occupational requirements, and some high-risk occupations (aerial work, underground miners, truck drivers) are denied.

With the improvement of people's quality of life, many friends began to have the awareness of buying insurance, the purpose of people to buy is mainly to avoid the risks in life, but I believe that many friends have heard of the situation of insurance refusal to compensate, once the insurance refuses to pay, it is easy to make people feel that the insurance is deceiving, but in fact, any refusal is not without reason, generally the following six situations, insurance will refuse to pay.

1. It is not covered by insurance. If you buy insurance, you can't make a claim after the accident, usually because you don't understand the insurance liability, if it is not covered by the insurance, then the insurance company will naturally not pay. Therefore, when we buy insurance products, we must pay attention to carefully read the insurance contract, do not blindly listen to the introduction of the insurance staff, in life insurance salespeople in order to promote products to exaggerate the insurance coverage of the matter is not uncommon, so it is necessary for us to understand the provisions of the treaty clearly.

2. Exclusions. The so-called exclusion of liability is what we often call the exemption of liability, which will indicate the scope of liability in the insurance contract, and the basic liability exclusion generally includes large risks that the insurance company cannot bear, such as war, nuclear radiation, etc.; In addition, it also includes illegal criminal acts, and the exemption clauses are different depending on the type of insurance.

3. Applying for insurance with illness and deliberately concealing it. For example, when purchasing medical insurance such as critical illness insurance, the policyholder needs to truthfully inform his or her medical history, and if he or she knows that he has a disease but deliberately conceals his illness to apply for insurance. In this case, the insurance company has the right to refuse compensation.

4. Accidents during the waiting period. Usually in the purchase of disease, health insurance is a waiting period, the so-called waiting period refers to the observation period or exemption period, only after the waiting period, the insurance contract is officially effective, if there is an insured accident, but the insurance is still in the waiting period, then the insurance company can not compensate.

5. The claim information cannot be fully provided. After the policyholder applies for a claim report, the insurance company will notify the policyholder to submit relevant information, only to collect all the evidence required by the insurance company, and the insurance company can obtain compensation after the insurance company has approved it.

6. Less than the deductible. In medical insurance, there is generally a deductible, the so-called deductible is like the starting line in medical insurance, if the reimbursement amount is lower than the deductible, then the insurance company will not pay.

This is provided by Kangbo Finance, which focuses on the interpretation of financial hot events, the popularization of financial knowledge, adheres to professionalism, pursues fun, makes financial content that people can understand, and conveys financial value in a vivid and diverse way. Hope this helps.

The circumstances under which the insurance company refuses to pay are: 1. The driver is not qualified to drive or is drunk; 2. The loss of the insured road traffic accident is intentionally caused by the victim; 3. The accident occurred during the theft and robbery of the insured motor vehicle; 4. The property of the insured, or the property on the insured's motor vehicle; 5. The insured intentionally causes a road traffic accident.

The insurance contract has a legal nature, and both parties must perform it. There are usually three reasons for refusing to pay to you.

What are the reasons for the insurance company's refusal to settle a claim? Is insurance a lie?

According to statistics, the top reasons for the insurance company's refusal are: failure to tell the truth, not within the scope of insurance liability, insurance during the waiting period, and exemptions.

Failure to tell the truth: It is almost a one-vote veto in the medical critical illness claim. For health insurance, pre-existing diseases and symptoms are not covered, which is also clearly stipulated in China's insurance law.

Failure to tell the truth and taking out insurance with illness can cause problems for claims. Therefore, remember to tell the truth before applying for insurance.

Not covered by insurance: For example, critical illness insurance, some are not "paid immediately after diagnosis", but have some additional conditions, which need to be met to meet the claim criteria, such as: juvenile rheumatoid arthritis "claim conditions:

Refers to a systemic connective tissue disease in adolescence. It can present with chi-expansion fever, rash, arthritis, splenomegaly, lymphadenopathy, serositis, weight loss, neutrophilia, etc., and systemic symptoms may precede arthritis. At least one of the following conditions must be met:

1) Clinical and X-ray examination found obvious joint deformity, and at least three of the following joints were involved: hand joint, wrist joint, elbow joint, shoulder joint, knee joint, hip joint, ankle joint, spine joint, metatarsophalangeal joint; (2) Knee or hip replacement surgery has been performed for the purpose of **. In addition to the diagnosis of "juvenile rheumatoid arthritis", there are two additional conditions that need to be met.

Yes, the definition of "accident" in accident insurance is also different from the accident that we ordinary people understand, such as sudden death from running, altitude sickness, heat stroke, etc.

Waiting period: For critical illness insurance and medical insurance, the insurance company will set a waiting period, and if the illness or diagnosis is diagnosed during the waiting period, the insurance company will not pay.

Disclaimer: Each insurance contract has a relevant exclusion clause, if the exclusion clause is triggered, the insurance company will usually refuse to deal with the claim, the more common are: the policyholder's intentional injury to the insured, traffic accidents caused by drunk driving, etc.

Now there are some third-party legal service platforms for insurance claims on the Internet, I know a platform called Claims Help, they specialize in handling insurance claims disputes, and the lawyers settled in the platform are said to be all over the country, all of them are professional insurance lawyers, who can provide some constructive advice, you can ask them.