Dialysis claim rejected or cut?
Dialysis filters the blood when the kidneys fail. Haemodialysis is usually done in sessions of a few hours, several times a week. If your insurer has rejected or cut the claim, these are the reasons that come up most for dialysis, the rules that apply, and what to do next.
Why dialysis claims get rejected or cut
- Sessions treated as OPD because there is no overnight stay.
- Pre-existing kidney disease or non-disclosure of diabetes or high blood pressure.
- A cap on the number of sessions, or on the amount per session, if the policy has one.
- Peritoneal dialysis at home refused as domiciliary or outpatient treatment.
- The claim limited to the sum insured of the year the kidney disease was first found, when cover was increased later.
Rules that apply
- Pre-existing disease: a condition counts only if it was diagnosed or treated within 36 months before the policy started. After 60 months of continuous cover, a claim can’t be contested for non-disclosure except for established fraud.
- Under 24 hours in hospital: check your policy’s day care list. If dialysis is on it, a short stay is no reason to reject.
What decided these disputes
- Whether hospital records dated before the policy showed kidney disease decided most non-disclosure disputes.
- Where the insurer had no such records, or couldn’t show the patient knew of the disease, the claim was usually paid.
- Waiting periods and sum-insured limits written in the policy were usually applied as written.
Documents to keep ready
- The nephrologist’s advice for dialysis
- Kidney function reports (creatinine, eGFR) with dates
- Session-wise bills
- The discharge summary, the itemised final bill and the rejection or settlement letter
How to challenge the decision
Write to the insurer’s Grievance Redressal Officer, who must reply within 14 days. If that fails, use Bima Bharosa or go to the Insurance Ombudsman within one year. The guides below have the letter format and the steps.
Questions people ask
Is dialysis covered by health insurance?
Usually, yes, as a day care treatment. Check your policy for any limit on sessions or amounts.
Is peritoneal dialysis at home covered?
It depends on your policy wording. Some policies cover it wherever they cover dialysis, others treat it as home treatment and exclude it, so read the dialysis and domiciliary clauses.
If a kidney transplant is refused, can my dialysis still be paid?
It should be looked at separately. A waiting period or exclusion for the transplant doesn’t automatically cover dialysis and medicines that aren’t part of the transplant surgery, so ask for those to be assessed on their own.