Health claim rejected:
what to do next

Short version: get the reason in writing, check it against your policy wording, and complain in writing to the insurer's grievance officer. If that does not resolve it in about two weeks, escalate through IRDAI's Bima Bharosa portal, and then to the Insurance Ombudsman. None of it costs anything, and you do not need a lawyer to start.

Why health claims get rejected

Most rejections we see in Raipur fall into a handful of categories. Knowing which one you are dealing with tells you whether there is a case.

• Waiting periods. Most policies have an initial waiting period, longer waiting periods for named illnesses and procedures, and a waiting period for pre-existing diseases. A claim inside any of these is usually declined, which is why portability, which carries waiting periods already served, matters.
• Non-disclosure. A condition, medicine or past surgery that was not declared on the proposal form, even an innocent omission, is the single most contested reason. Insurers check hospital records for the history.
• Room-rent and sub-limits. Strictly these are deductions, not rejections. If you stay in a room above your policy's limit, many policies reduce associated charges in the same proportion, which can cut the claim far more than the room rent alone.
• Documentation. Missing discharge summary, investigation reports, original bills, or a mismatch between them. These are often fixable.
• Exclusions. Treatments the policy excludes, or treatment that the insurer says did not need hospitalisation.
• Lapsed policy. A renewal paid after the grace period, or a gap when changing insurers.

Step one: get the reason in writing

Ask the insurer, or its third-party administrator (TPA), for the rejection or deduction in writing, with the specific policy clause it relies on. A phone call saying "not payable" is not enough to act on. Then read that clause in your own policy wording, the full document, not the brochure, and the policy schedule for your sum insured, sub-limits and the date cover started.

Many disputes end here. Either the clause clearly applies and the rejection is right, or it does not, and you now have a precise argument and the documents to support it.

Step two: complain to the insurer

Every insurer has a grievance redressal officer. File a written complaint, by email or through the insurer's grievance channel, setting out the claim number, the reason given, why you disagree, and the documents that answer it. Keep the acknowledgement. According to IRDAI's Bima Bharosa guidance, the insurer should resolve the complaint within about two weeks.

Step three: escalate to IRDAI through Bima Bharosa

If the insurer does not resolve your complaint within about two weeks, or you are not satisfied with its reply, you can escalate to IRDAI's Grievance Redressal Cell through the Bima Bharosa portal, or by calling the toll-free number 155255. Two points from IRDAI's own guidance:

• The portal does not ask for payment of any kind. Anyone asking you to pay to "fast-track" a complaint is not from IRDAI.
• The complaint must come from the policyholder. IRDAI does not entertain complaints filed by agents or other third parties on a policyholder's behalf.

Step four: the Insurance Ombudsman

The Insurance Ombudsman, set up under the Insurance Ombudsman Rules, 2017 and administered by the Council for Insurance Ombudsmen, resolves individual policyholders' disputes with insurers. You can approach the Ombudsman if the insurer has rejected your complaint, has not replied within one month, or has replied in a way you are not satisfied with. The key conditions:

• The complaint should generally be filed within one year of the insurer's rejection or final reply.
• The compensation sought cannot exceed ₹50 lakh.
• There is no fee, and you do not need a lawyer.

Each Ombudsman office covers a defined territory; the Council's website lists which office covers Chhattisgarh.

How to prevent a rejection in the first place

• Disclose everything on the proposal form, including conditions controlled by medication. A higher premium or an exclusion is far better than a rejected claim.
• Know your room-rent limit before admission, and choose the room accordingly.
• Renew on time, and use portability when changing insurers so waiting periods served carry over.
• Use network hospitals for planned treatment and get pre-authorisation early. See cashless hospitals in Raipur.
• Keep every document: discharge summary, reports, prescriptions, original bills and payment receipts.

How we help our clients

For policies placed through us, claim support is included at no extra charge: we help with pre-authorisation and reimbursement paperwork, follow the claim with the insurer, and if it is rejected, help you prepare a clear written complaint with the right documents. The complaint itself is filed in your name, and the decision rests with the insurer, IRDAI's process or the Ombudsman. We cannot promise an outcome; we can make sure your case is put properly.

If your policy keeps falling short, the problem may be the policy itself. Our health insurance and mediclaim page explains how we review cover for families and parents. Insurance is the subject matter of solicitation.