Health Insurance Claim Rejected
Immediate Actions — First 30 Minutes
1
Read the rejection letter carefully and note the exact stated reason — ‘non-disclosure,’ ‘exclusion,’ ‘waiting period,’ ‘pre-existing condition,’ ‘policy lapsed,’ ‘procedure not covered,’ etc. The reason determines your next step.
2
Do not accept the rejection as final on the day you receive it — you have multiple levels of appeal.
3
Pull out your policy document and read the relevant clause that the insurer is citing. Many rejections cite clauses incorrectly or apply them too broadly.
4
Gather all documents: original hospitalisation records, bills, claim form, and any previous correspondence with the insurer.
Short-Term Steps — First 48 Hours
1
Respond to the insurer’s rejection letter in writing within 15 days, specifically addressing their stated reason. Attach supporting documents that counter their grounds.
2
Common grounds you can challenge:
(a) Pre-existing condition not disclosed: if the policy has been renewed for 5 continuous years (60 continuous months), the moratorium period protects you.
(b) Waiting period: check if the exact condition was truly subject to a waiting period under your policy.
(c) Experimental treatment: get a medical opinion confirming the treatment is standard, not experimental.
(d) Non-network hospital: confirm whether pre-auth was sought within the required timeframe during an emergency.
(a) Pre-existing condition not disclosed: if the policy has been renewed for 5 continuous years (60 continuous months), the moratorium period protects you.
(b) Waiting period: check if the exact condition was truly subject to a waiting period under your policy.
(c) Experimental treatment: get a medical opinion confirming the treatment is standard, not experimental.
(d) Non-network hospital: confirm whether pre-auth was sought within the required timeframe during an emergency.
3
Escalate to the insurer’s internal grievance officer (contact details must be in the policy document and on the insurer’s website). Request a review by a senior officer.
4
Keep a written record of all communications — dates, persons spoken to, and what was said.
Resolution Steps — Next 2–4 Weeks
1
If the insurer’s internal grievance process does not resolve the matter within 30 days: file a complaint with the Insurance Ombudsman — this is free, fast (typically 3 months), and binding on the insurer for amounts up to ₹50 lakh.
2
The Insurance Ombudsman frequently rules in favour of claimants on pre-existing condition disputes, especially where the insurer cannot prove the customer knowingly concealed information.
3
If the Ombudsman ruling is also unsatisfactory: approach the Consumer Disputes Redressal Commission (consumer forum) or civil court.
4
For unjust or arbitrary rejections: IRDAI’s Bima Bharosa portal (bimabharosa.irdai.gov.in) accepts direct complaints against insurers.
Prevention — How to Avoid This in Future
✓
Disclose all pre-existing conditions truthfully at the time of policy purchase — non-disclosure is the single biggest cause of claim rejection.
New health insurance policies carry a 30-day free-look period, during which the policyholder may cancel the policy and obtain a refund after deduction of applicable charges. The 30-day clock begins from the date of receipt of the physical or electronic policy document, not from the purchase or commencement date.
New health insurance policies carry a 30-day free-look period, during which the policyholder may cancel the policy and obtain a refund after deduction of applicable charges. The 30-day clock begins from the date of receipt of the physical or electronic policy document, not from the purchase or commencement date.
✓
Read the exclusions section of your policy carefully before buying — not after a claim is filed.
✓
Renew your policy without a break every year — continuous coverage builds moratorium protection.
✓
Keep copies of all claim documents submitted — you need them if the claim is disputed.
✓
Buy from reputed insurers with a high claim settlement ratio (published by IRDAI annually).
Watch Video Guide
Your Rights
IRDAI regulations require insurers to provide specific written reasons for claim rejection. Insurers cannot reject claims citing conditions that were not clearly excluded in the policy. After 5 continuous policy years (moratorium), no claim can be rejected on the grounds of non-disclosure or misrepresentation of pre-existing conditions (unless a fraud can be proven). The Insurance Ombudsman can award claims up to ₹30 lakh at no cost to the claimant.
Key Contacts & Portals
| Who / What | Contact / Action |
|---|---|
| IRDAI Bima Bharosa | bimabharosa.irdai.gov.in | 155255 |
| Insurance Ombudsman (Nearest) | irdai.gov.in/web/guest/find-ombudsman |
| Consumer Forum (Online) | edaakhil.nic.in |
| Who / What | Contact / Action |
|---|---|
| IRDAI Grievance Call Centre | 155255 or 1800 4254 732 (toll-free) |
| Your insurer’s grievance officer | Details in policy document — compulsory disclosure |