How to effectively avoid insurance denials?

There are several elements that need to be met to obtain effective compensation, firstly, the accident must be within the scope of liability stipulated in the insurance contract, and if the liability scope agreed in the insurance contract is exceeded, the insurance company may not be liable for compensation or payment of insurance money. Whether the insurance company pays money or not is often related to the insurance period. When an insured event occurs, it depends on whether the insurance contract is valid, whether it is within the waiting period (observation period), and whether it is still within the statute of limitations when making a claim, which is directly related to whether the insurance company loses money.

Whether the insurance company pays money or not, and how much it loses, is also related to the amount of compensation the customer demands. If a policy stipulates that the maximum compensation amount is 100,000 yuan, and the policyholder has received a claim of 60,000 yuan, then in case of another insured accident, the consumer can only get a maximum of 40,000 yuan in compensation, and the excess part will be refused by the insurance company. In the case of insurance companies' refusal to make claims, consumers also account for a large proportion of the failure to make actual information when applying for insurance.

An important principle of the insurance contract is that the policyholder needs to bear the obligation to "tell the truth". A small "concealment" when applying for insurance can easily lead to the loss of the right to claim claims in the future. In addition, for example, some policyholders fail to pay premiums on time until the "grace period" has passed, after which the insurance contract will lapse and the insurance company will refuse to pay in case of an insured event.

In addition, when applying for a claim, if the necessary claim documents and materials are missing, the claim will also be denied. If the statute of limitations for claiming a claim is exceeded, or if the insured event is falsely declared, it is naturally easy to be denied. This avoids insurance denials.

If you really need to pay for your losses, but the insurance company refuses to pay for it, this is a legal process, you can find a lawyer.

to help you solve this problem effectively.

Sound advice. 1.In the event of an accident, you can find the nearest hospital that can issue a formal invoice on the first day**, but you need to transfer to a hospital designated or approved by the insurance company on the second day** (on the first day of the accident injury, you can directly choose the hospital that meets the conditions for compensation and reimbursement, and you must choose the hospital that meets the conditions for compensation and reimbursement for hospitalization).

Generally, there will be designated hospitals in the insured place or adjacent areas, and hospitals above the second level (urban districts and county-level hospitals in rural areas are eligible) in other places that are not designated are recognized.

2.No matter what the reason is when you need to seek medical treatment, if possible, it is best to notify me before seeking medical treatment, so as to provide the matters that need attention in time, avoid unnecessary troubles and avoid negligent reasons that lead to denial of compensation or regret of compensation (my research has found that many cases of refusal or regret of compensation are human errors that can be completely avoided in some detailed sections).

3.If you have medical expenses, you must tell the doctor as soon as possible that you want to go to the insurance company for reimbursement, and you need to meet the social medical drug standards.

Special Instructions. 1.If the hospital is not reminded, the insured is likely to be greedy for convenience to find the nearest informal hospital or general small outpatient department**, resulting in a denial of the claim.

2.If it is not clearly emphasized that the fall was injured, the doctor may only say in the medical record that the patient is coming to the doctor with severe pain in the lower back (which can be understood as the pain may be due to other medical causes and cannot prove that it was indeed the severe pain caused by the fall); At the same time, the doctor may not mention the word "compression" in the diagnosis, because in the eyes of the doctor, these are not important, but they may be very important to whether or not the claim can be made.

3.If there is no indication that the drug needs to be met, both the patient and the doctor may pursue the use of expensive drugs and other self-paid drugs, resulting in some medical expenses being unreimbursable.

Personally, I feel that insurance companies are subject to the supervision of the China Banking and Insurance Regulatory Commission and are subject to the Insurance Law, and their claims must be clear and reasonable.

Once the insurance company does deny a claim, it is often due to the following reasons:

1. It is not covered by insurance.

Some friends may be confused when buying insurance, and they don't know what they bring with them in the purchase and sale;

There are also some friends who encounter unprofessional insurance salesmen and do not explain the terms of the contract;

However, different insurances have different functions, and if they are not covered by the insurance, the insurance company will naturally not be able to pay for it.

2. There is no truthful health notice.

When buying health insurance such as critical illness insurance and medical insurance, we all need to inform about our health and some health problems. As long as the health notice asks, we must tell the truth.

If you don't tell you about the illness you asked, or if you deliberately conceal it, even if you successfully apply for insurance, the insurance company will refuse to pay if you are out of danger.

3. Pre-existing conditions are not compensated.

Pre-existing conditions, which are well understood, are diseases that were pre-existing before buying insurance.

So, how are pre-existing conditions defined? Is it a pre-existing disease?

4. Within the waiting period.

The waiting period, also known as the insurance company's observation window.

Accidents during the waiting period are usually not compensated, mainly to prevent someone from taking out insurance with illness.

The waiting period is generally calculated from the effective date or reinstatement date of the loss contract, and there is generally only one waiting period, and there is generally no waiting period for renewal.

5. Failure to seek medical treatment in the hospital agreed in the contract.

This is mostly seen in medical insurance, which usually has a set of requirements and restrictions for the hospitals that are reimbursed.

In short, the above 5 are the most common reasons for insurance companies to refuse claims, and of course, the reasons for denial are not limited to these. It is always good for everyone to know a little more before buying insurance, which is conducive to avoiding potential claims disputes.

Summary. The reason for the insurance company's refusal to pay compensation is actually the problem in the insurance contract itself, the insurance contract provided by the insurance company often stipulates a series of exemption clauses, some of which may be invalid clauses, but as the policyholder has no absolute choice for this, only the relative right to choose, because almost all insurance companies have similar agreements on this part, and the policyholder has almost no other choice to sign the contract in a knowing situation. Therefore, when purchasing insurance, the policyholder should ask the insurance company to clarify the specific division of the scope of compensation and the exemption part in the insurance contract as much as possible.

Hello, I am honored to answer for you If the insurance company fails to fulfill its obligation to inform, you can negotiate with the insurance company first, and raise it on the grounds of failure to inform, if you fail to negotiate, you can file a lawsuit with the court. If the insurance company still refuses to pay if the insurance company is eligible for compensation, the effective way is to sue the insurance company. In insurance claims, denials by insurance companies often occur.

The reason for the insurance company's refusal to pay compensation is actually the problem in the insurance contract itself, the insurance contract provided by the insurance company often stipulates a series of exemption clauses, some of which may be invalid clauses, but as the policyholder has no absolute choice for this, only the relative right to choose, because almost all insurance companies have similar agreements on this part, and the policyholder has almost no other choice to sign the contract in a knowing situation. Therefore, when purchasing insurance, the policyholder should ask the insurance company to clarify the specific division of the scope of compensation and the exemption part in the insurance contract as much as possible.

Insurance, which is meant to be safe and reliable; It is a tool used to plan life finances, a basic means of risk management under the conditions of market economy, and an important pillar of the financial system and social security system.

Insurance refers to the commercial insurance behavior in which the insured pays the insurance premium to the insurer in accordance with the contract, and the insurer bears the responsibility for compensating for the property loss caused by the occurrence of the accident that may occur as agreed in the contract, or the insured bears the responsibility of paying the insurance money when the insured dies, is disabled, sick, or reaches the age and time limit agreed in the contract.

From an economic point of view, insurance is a financial arrangement for apportioning the loss of an accident; From a legal point of view, insurance is a contractual act, a contractual arrangement in which one party agrees to compensate the other party for its losses; From a social point of view, insurance is an important part of the social and economic security system, and it is an "exquisite stabilizer" of social production and social life. From a risk management perspective, insurance is a method of risk management.

Legal analysis: If the insurance company does not settle the claim, it can first negotiate with the relevant personnel of the insurance company to deal with the claim and try to resolve the claim dispute. If the negotiation fails, you can go to the special complaint center of each insurance company to handle the complaint and ask the insurance company to handle the claim as soon as possible.

If the problem is still not solved, you can go to the CIRC for complaint handling.

Legal basis: "Road Traffic Safety Law of the People's Republic of China" Article 74 In the case of a dispute over compensation for damages caused by a traffic accident, the parties may request mediation from the traffic management department of the public security organ, or may directly file a civil lawsuit with the people's court. After mediation by the traffic management department of the public security organ, if the parties fail to reach an agreement or do not perform after the mediation agreement takes effect, the parties may file a civil lawsuit with the people's court.

It is literal, the insurance company refuses to compensate, and there are many reasons for refusing to compensate, it may be that you are sick and hospitalized or have an accident, but you buy an annuity insurance and there is no accident, hospitalization, or serious illness; It may also be that the insurance company did not tell the truth when it was insured, and the insurance company found out when it was verified; There are so many of these reasons that you need to understand them all to know why you are denying a claim. Property insurance refusal, in the process of insurance claims, the insurer does not accept the policyholder's claim for compensation, is a refusal. The main reasons for this are:

The damage was not caused by a specific disaster within the scope of the insurance liability, or was clearly excluded; The damage is caused by the intentional act, gross negligence or illegal act of the policyholder, the insured or other interested parties; Violating the principle of good faith, such as concealing material true information when applying for insurance, making false declarations and taking out insurance as a result, or falsifying after the accident in an attempt to defraud compensation; The insured seriously ignores safety laws and regulations, fails to implement safety and disaster prevention recommendations and goes out of danger, or does not actively rescue after the accident and allows the loss to expand; The damaged property is not the subject of the insurance or the time of the insurance is not within the validity period of the insurance; If the insurance property is transferred without going through the procedures for changing the name and transferring the ownership, the new owner is not a party to the contract and cannot enjoy the insurance benefits.

The insurance company may deny a claim under the following circumstances:

1. Insured accidents are not covered by insurance;

2. Exemption from liability during the waiting period, even if the insured is out of danger within the specified period when the insurance contract is in effect, the insurance company may not compensate;

3. Insurance exemption from liability;

4. Failure to pay insurance premiums on time;

5. The insured commits suicide or intentionally commits a crime.

[Legal basis].

Article 43 of the Insurance Law of the People's Republic of China.

If the insured intentionally causes the death, disability or illness of the insured, the insurer shall not be liable to pay the insurance money. If the policyholder has paid the insurance premium for more than two years, the insurer shall refund the cash value of the insurance policy to the other right holders in accordance with the contract.

If the beneficiary intentionally causes the death, disability or illness of the insured, or intentionally attempts to kill the insured, the beneficiary loses the right to benefit.

Article 45 of the Insurance Law of the People's Republic of China.

If the insured intentionally commits a crime or resists the criminal compulsory measures taken in accordance with the law, resulting in his disability or death, the insurer shall not be liable to pay the insurance money. If the policyholder has paid the insurance premium for more than two years, the insurer shall refund the cash value of the insurance policy in accordance with the contract.

Since you can ask such a question, then prove that ours has no effect on you, in other words, you will not easily believe our words, then you should seriously study the terms of the insurance with the sincerity of self-exaltedness.

Here I need to remind you that although the insurance is very thick, don't be afraid, most of them are the general terms of the country, this part of the content just pay attention to the refusal of compensation, open the insurance contract, find the insurance liability, read every word in detail, you will understand this insurance, what kind of protection will it bring you after you buy it. If it is critical illness insurance, be sure to find the definition of critical illness in the insurance contract, you don't need to read all the critical illnesses, you just need to find a similar illness that your family members are suffering from, and see if its insurance liability meets your requirements.

If you are buying insurance for children under the age of 18, most insurance companies on the market now sell products that do not cover the amount of insurance for children under the age of 18, and the compensation is the premium you have paid.

Hope mine will be helpful to you.