Health insurance claim rejected: what to do next

A claim rejection arrives at the worst possible moment — usually while someone is still in hospital, or just after the family has paid the bill themselves. Most people read the letter, feel cheated, and stop there. That is exactly what the process counts on.

There is a defined escalation path, it costs nothing, and at the end of it sits an authority whose decision the insurer must follow. Here is the order, and what each step needs from you.

First, find out what they actually said

A rejection letter must state the reason and the policy clause it relies on. If yours does not name a clause, that is your first question in writing. The common reasons are narrower than they sound:

• Waiting period — the condition is covered, but not yet. Specified illnesses and joint replacements usually wait two to four years.
• Pre-existing condition not disclosed when the policy was bought.
• Treatment excluded by the policy wording — cosmetic, dental, or an experimental procedure.
• Admission not medically necessary, or shorter than the policy's minimum hospitalisation.
• Intimation delayed beyond the window the policy allows.
• Non-medical items — gloves, syringes, belts — which were never payable in the first place.

The distinction that matters: a partial deduction is not a rejection. If most of the bill was paid and a slice was cut, the argument is about specific line items, and that is a different, easier conversation.

Step 1 — the insurer's grievance cell

Every insurer has a Grievance Redressal Officer, separate from the claims team that said no. Write to them, not to the branch. Quote the claim number, the rejection date, the clause they cited, and why it does not apply — in that order, in one page. Attach the discharge summary, the itemised bill and the rejection letter.

Ask for a written response and keep the acknowledgement. Insurers are expected to resolve a grievance within about two weeks; a silence past that is itself grounds to escalate.

Step 2 — the regulator's complaint portal

If the grievance cell refuses or does not reply, the complaint goes to IRDAI through its Bima Bharosa portal. This does not decide your case — it registers it against the insurer and pushes the company to respond, which on its own resolves a fair number of claims. Keep the token number it gives you.

Step 3 — the Insurance Ombudsman

• Find the Ombudsman office for the city where the insurer's branch is located, or where you live.
• File online or on paper, with a simple statement of facts and the documents from step one.
• There is no fee at any stage, and no requirement to hire anyone.
• Hearings are informal — you can present the case yourself.

What to keep, from day one

• The policy wording — not the brochure. Only the wording decides a dispute.
• Pre-authorisation approvals and any written estimate from the hospital.
• The itemised bill, the discharge summary and all diagnostic reports.
• Every email and the acknowledgement of each complaint, with dates.

One habit prevents most rejections outright: declare every condition when you buy, even the ones that feel irrelevant. Non-disclosure is the single reason insurers rely on most, and it is the hardest to argue away afterwards.