Health insurance claim rejected? Here’s what to do next.

1. Read the reason the insurer gave

Every rejection or partial payment must be communicated with “full details giving reference to the specific terms and conditions of the policy document”. If your letter only says “not payable” without naming a clause, that is already a weakness in the insurer’s decision.

Note the clause number, the exact words of the reason, and the date of the letter. The date matters for every deadline that follows.

2. Check the most common grounds against the rules

• Pre-existing disease: a condition only counts if it was diagnosed or treated within 36 months before the policy started, and its waiting period is capped at 36 months of continuous cover.
• Non-disclosure: after 60 months of continuous cover (ported and renewed years count), the insurer cannot contest the claim for non-disclosure except for established fraud.
• Waiting periods: specific-disease waiting periods are capped at 36 months and never apply to treatment needed because of an accident.
• Missing documents or late intimation: IRDAI says no claim shall be rejected or closed for want of documents or for delayed intimation. The insurer or TPA must collect documents from the hospital.
• Deductions: room-rent caps, sub-limits and co-payment must be stated in your policy wording. If they aren’t there, there is no basis for the cut.

3. Write to the insurer’s Grievance Redressal Officer

Send a short written complaint (email is fine) to the insurer’s Grievance Redressal Officer. State the claim number, the reason you disagree, and the rules that support you. Attach the rejection letter, policy schedule and discharge summary. Keep proof that you sent it.

• The insurer must acknowledge immediately and resolve the complaint within 14 days.
• If the claim was simply delayed, reimbursement claims must be settled within 15 days of submission, with interest at bank rate plus 2% if late.

4. Escalate to the Insurance Ombudsman

If the insurer rejects your complaint, doesn’t reply within one month of receiving it, or you’re not satisfied with its reply, you can complain to the Insurance Ombudsman. It is free, it can award up to ₹50 lakh including expenses, and you can file online at cioins.co.in. You must file within one year of the insurer’s final reply.

• The Ombudsman aims to give an award within 3 months of receiving everything from you.
• The insurer must comply with the award within 30 days, or pay you ₹5,000 for every day of delay.

5. Or go to the consumer commission

You can approach the District Consumer Commission instead, within 2 years of the rejection. Choose one forum: you can’t take the same complaint to the Ombudsman if a consumer case on it is pending or decided.