Quick Summary
This blog explains why maternity health insurance claims get rejected, what maternity cover actually includes, and the most common exclusions.
Understanding the limits of maternity cover in group health insurance
Many people believe that once they have a group health insurance policy with maternity cover, most pregnancy-related expenses will be taken care of automatically. However, the reality is very different.
In most cases, maternity health insurance claim rejections happen due to paperwork mistakes or errors by the insured, policy exclusions, conditions, and sub-limits that people are unaware of at the time of buying or using the policy.
Maternity health insurance is designed to primarily cover hospitalization expenses related to childbirth, not the entire pregnancy journey. Expenses incurred before hospitalization or after discharge are often excluded unless specifically mentioned in the group health insurance policy.
Most common reasons for maternity health insurance claim rejection
The reasons below are common across many group health insurance policies, but they may not apply to every plan. This is why it is essential to carefully read your policy document and maternity clauses before planning or filing a claim.
Complications from unrecognized or illegal procedures
Insurers strictly exclude expenses arising from treatments or procedures that are:
- Not recognized by medical authorities, or
- Illegal under Indian law
For example, if complications come from illegal pre-natal gender determination tests, the claim will be rejected. Insurance companies follow regulatory and ethical guidelines and will not pay for consequences of such procedures.
Medical expenses of ectopic pregnancy
An ectopic pregnancy occurs when the pregnancy develops outside the uterus, usually in a fallopian tube. Most maternity insurance maternity cover does not include ectopic pregnancies, as they are treated as a medical complication rather than a normal maternity event.
Consultation and diagnostic tests are not covered
Many people assume that OPD visits during pregnancy are covered. In reality, most maternity health insurance policies do not cover:
- Regular doctor consultations
- Ultrasounds
- Blood tests
- Routine pregnancy check-ups
These expenses are typically covered only when you are hospitalized for delivery. This becomes one of the biggest surprises for first-time parents.
Multiple births and medical termination of pregnancy(MTP)
As per guidelines issued by IRDAI, maternity insurance policies typically cover:
- A maximum of two births in a lifetime
- A maximum of two legal medical termination of pregnancy (MTP) procedures
Claims may be rejected in situations such as:
- Births beyond the allowed limit
- Policies that cover only one birth per pregnancy
- Special cases like twins or triplets, if the policy terms do not allow it
Always refer to policy wording if multiple births are expected.
Infertility treatments like IVF are not covered
Maternity health insurance policies do not cover:
- IVF (in vitro fertilisation)
- IUI
- Fertility medications or procedures
This often creates confusion because people expect the health insurance for maternity to include infertility treatment. However, insurers treat infertility as a separate category and exclude it unless a specific rider is mentioned.
Late pregnancy (above 45 years)
Many maternity insurance policies impose an age cap. Pregnancies after the age of 45 are often excluded due to higher medical risk and increased likelihood of complications This exclusion is clearly stated in the group health insurance policy documents.
Treatment from unrecognized hospitals or providers
Maternity insurance usually supports treatment only at:
- Network hospitals
- Recognized doctors and facilities
Understanding the difference between cashless and reimbursement claims is critical.
Alternative or natural birth methods
Expenses related to alternative birth methods such as:
- Water birth
- Hypnobirthing
- Home birth setups
may not be covered unless explicitly approved by the insurer. Claims are often rejected when these methods are classified as non-standard procedures. Pre-approval from the insurer is essential in such cases.
Non-medical expenses are always rejected
All maternity health insurance policies exclude expenses that are not considered medically necessary. These include:
- Diapers
- Personal comfort items
- Vitamins
- Calcium tablets
- Protein powders
Even though these items are essential for newborn care, insurers classify them as non-medical consumables, which leads to automatic claim rejection.
If the actual hospital bill exceeds these limits, the remaining amount must be paid by the insured.
C-section delivery vs normal delivery — where claims get stuck?
Normal delivery is a natural vaginal birth with quicker recovery, lower risk of complications, and usually lower medical costs. C-section delivery is a surgical procedure used when medically necessary, involves longer recovery, higher costs, and slightly higher risk of complications.
Claims often get partially rejected when:
- Cesarean delivery costs exceed policy sub-limits
- Room rent restrictions indirectly reduce payable amounts
- Overall maternity insurance maternity cover caps are crossed
How to avoid maternity health insurance claim rejection?
You can significantly reduce rejection risk by:
- Checking maternity waiting periods before planning pregnancy
- Understanding delivery sub-limits for normal and C-section delivery
- Confirming network hospital eligibility in advance
- Clarifying exclusions such as IVF, ectopic pregnancy, and supplements
- Getting pre-authorization wherever possible
Maternity health insurance in group health insurance works best when employees know exactly what’s covered. Pazcare bridges the gap between policy documents and real-life usage by helping employees understand maternity benefits, delivery limits, and claim processes before they need to use them.
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