ClaimRejected data
What 1,060 Ombudsman awards
say about health claims.
We classified every published Insurance Ombudsman award on a health claim that we could collect, 2004 to 2021, by the insurer’s reason for rejection and by what the Ombudsman decided.
Outcomes by the insurer’s reason for rejection
| Reason the insurer gave | Awards | Paid in full | Paid in part | Dismissed | Policyholder got something |
|---|---|---|---|---|---|
| Deductions and part payments | 243 | 94 | 105 | 44 | 82% |
| Hospitalisation not needed, or under 24 hours | 159 | 70 | 31 | 58 | 64% |
| Pre-existing disease or waiting period | 219 | 81 | 22 | 116 | 47% |
| Non-disclosure or misrepresentation | 176 | 64 | 13 | 99 | 44% |
| Policy exclusions | 150 | 54 | 15 | 81 | 46% |
| Documents or late intimation | 16 | 7 | 2 | 7 | 56% small sample |
| Alleged fraud | 20 | 8 | 0 | 12 | 40% small sample |
| Other reasons | 77 | 37 | 12 | 28 | 64% |
“Policyholder got something” counts awards that ordered the insurer to pay in full or in part.
What stands out
- Deduction disputes are the easiest to win, but usually only in part. In 82% of them the policyholder got money back, but over half of those were part payments.
- History-based rejections are close to a coin toss. Non-disclosure and pre-existing disease disputes went the policyholder’s way 44% and 47% of the time. The facts that decide them, like dates of diagnosis and what the proposal form asked, are in your documents.
- “Not medically necessary” rejections are often overturned. The policyholder won in 64% of these.
- Results improved over time. 40% in 2004–2011 (206 awards), 58% in 2015–2017 (593 awards) and 75% in 2021 (193 awards).
How we built this
- Source: award compilations published by the Insurance Ombudsman system and the Council for Insurance Ombudsmen. We include only health insurance claims.
- Method: we classified each award by the main reason the insurer gave for rejecting or cutting the claim, and by the result: paid in full, paid in part, or complaint dismissed.
- What we don’t publish: names, case details or figures for any individual insurer. This page shows totals only.
Limits
- These are the awards that were published. Complaints settled or withdrawn before an award aren’t here, and published awards may not represent every complaint.
- The awards date from 2004 to 2021, before IRDAI’s 2024 master circulars. Some rules have changed since then, such as the moratorium (now 60 months) and the cap on waiting periods (now 36 months).
- Past awards don’t predict any one case. What matters is your policy wording, your documents and the insurer’s exact reason.
Data as of 12 November 2026. You’re welcome to quote these figures with a link to this page.
Next steps
- Check whether you can file yet, and the last date, with the Ombudsman deadline checker.
- Read how to file in the Ombudsman complaint guide, and find your Ombudsman office.
- Complain to the insurer first, using the complaint letter format.
Questions people ask
How often do policyholders win at the Insurance Ombudsman?
In 1,060 published health-claim awards from 2004 to 2021, the Ombudsman ordered the insurer to pay in full or in part in 58% of cases, and in full in 39%.
Which health claim disputes do policyholders win most often?
Disputes over deductions, such as reasonable-and-customary cuts and room-rent limits: the policyholder got something back in 82% of 243 awards, though usually only part of the amount.
Is it worth going to the Insurance Ombudsman?
It is free and needs no lawyer, and in these awards policyholders won more often than not. But every case turns on its own policy wording and documents, so past awards don’t tell you how yours will go.
We’re on your side
of the claim.
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