Rejected Health Claim: Response Steps

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What the Issue Means

Ask for the complete written reason and the exact policy term relied upon. IRDAI’s health master circular requires repudiation or partial disallowance to refer to specific policy terms, and final repudiation decisions must pass through the prescribed claims-review structure.

Compare the reason with the policy schedule, Customer Information Sheet, proposal form, medical records, waiting periods, exclusions and pre-authorisation communication. A hospital’s description can differ from the medical facts, so obtain the discharge summary and treating-doctor clarification where needed.

Use the insurer’s grievance process first. If unresolved, Bima Bharosa and the Insurance Ombudsman route may be available subject to their conditions and jurisdiction.

Action Steps

1. Obtain the written rejection or deduction letter.
2. Identify the exact clause cited.
3. Collect the complete policy and proposal form.
4. Ask the hospital for medical and billing records.
5. Prepare an issue-wise representation.
6. Escalate through insurer, Bima Bharosa and Ombudsman where eligible.

Decision Table

Practical Example

Evidence to Keep

• Policy schedule, wording and Customer Information Sheet.
• Proposal form and medical declarations.
• Pre-authorisation and insurer correspondence.
• Discharge summary, investigation and doctor note.
• Itemised hospital bill and payment proof.
• Rejection, grievance and escalation records.

Common Mistakes

Escalation Route

IRDAI’s grievance portal does not charge a fee and warns users against QR-code or payment demands. Register only through official channels.

Where the dispute turns on medical causation, non-disclosure or a large amount, obtain professional medical and legal assistance. A grievance summary cannot replace expert evidence.

Working Principle

The safest approach is to preserve the original record, use the official channel and explain the facts in chronological order. A portal acknowledgement, complaint number or filing receipt is part of the evidence and should be downloaded rather than assumed to remain available forever.

Rules and procedures can change, and the correct action depends on the exact transaction, policy, notice or account. Where money, limitation, criminal allegations, medical causation or a large tax position is involved, qualified professional advice should be obtained before taking an irreversible step.

Why Timing Matters

Health-insurance disputes are won or lost on policy wording, medical facts and the chronology of authorisation. The first practical step is Obtain the written rejection or deduction letter. Obtain the exact clause, request and response in writing rather than relying on an agent, hospital desk or call-centre summary.

The claim file should start with Policy schedule, wording and Customer Information Sheet. Add the proposal form, Customer Information Sheet, discharge summary, itemised bill, medical reports and every approval or deduction sheet. Where the insurer relies on a waiting period, exclusion, non-disclosure or sub-limit, map that clause to the actual diagnosis, treatment date and declared history.

Cashless approval is not the same as final admissibility, and payment by the patient does not prevent a reimbursement review. A common mistake is Relying only on the agent’s promise. Escalate within the insurer’s grievance structure while preserving the limitation period for the Ombudsman or another remedy.