If your health insurance claim has been denied, there’s no need to panic because you’ll still have a chance of getting your money back. Health insurance is primarily designed to assist you financially in case of illness or emergency. However, sometimes your insurance provider may deny your health insurance claim. If this happens, there is no need to despair – you can recover your money with the right information and process.

It is first important to understand the reason for the denial. The insurance company must provide a reason for the denial in writing and that reason is typically found in the terms and conditions of your policy. Typical reasons include not disclosing certain pre-existing diseases, providing misinformation, or not submitting documents on time.

Carefully Read the Denial Letter

Read your denial letter closely and identify the actual reason your claims was denied. If you think the reason for the denial is not appropriate, you should contact the insurance company right away. You can contact their customer care or Grievance Redressal Officer and explain your issue. Sometimes, minor application errors such as documents being missing or incomplete application can be fixed and you may still have your claim approved.

Seek Help from IRDAI

If the company does not listen to you, contact the Insurance Regulatory and Development Authority of India (IRDAI). IRDAI has an online portal where you can file your complaint. You will need your policy number, claim number, and a copy of the rejection letter. IRDAI will check your complaint and ask the company to respond. Many times, this helps in getting your claim approved.

If the issue is still not rectified, you can contact the Insurance Ombudsman. This is a free service that attempts to settle matters quickly for some small amounts. It is important that you make your appeal, within a year of claim rejection.

If you have a large claim and the insurer has treated you harshly or unfairly you can go to the consumer court. You could hire an attorney for this, however, where the claim is smaller you may find this is simply not worth it. Therefore, it is best to try and talk to the company and IRDAI first. In the meantime, you should read your policy terms and condition thoroughly. Many times people have hidden illnesses or hospital visits that will lead simply to rejections. Lastly always submit bills, test reports and your doctor’s prescriptions in a timely manner.

If you stay careful from the beginning, the chance of claim rejection will be very low. Always give correct and complete information when buying a policy. If you have doubts, talk to an insurance agent or financial advisor. These steps will help you protect your rights and get financial help in hard times.

If your health or life insurance company rejects your claim without reason or delays payment, you can directly complain to the Insurance Ombudsman for free and get justice.

What is the Insurance Ombudsman?

The Insurance Ombudsman is an independent body that solves problems between customers and insurance companies. It helps customers get a fair and quick solution without going to court.

You can contact the Ombudsman if the company does not reply or if you are not happy with their reply. You must do this within one year of claim rejection. Complaints after one year are not accepted.

You can file a complaint in these cases:

Delay in claim settlement (more than 15 days)
Claim fully or partly rejected
Dispute about premium amount
Wrong or unclear information in the policy
Poor service from agents or brokers
Policy not issued as promised
Policy not given even after payment
Violation of IRDAI rules or ignoring customer interest
Documents Needed to File a Complaint

Before going to the Ombudsman, first file a written complaint with your insurance company. If they don’t solve it within 30 days, then you can go to the Ombudsman.

You will need these documents:

Copy of complaint letter sent to the insurance company
KYC documents (Aadhaar, PAN, or driving license)
Rejection letter from the company
Copy of your insurance policy
All medical records and claim papers
Passport-size photo (for online complaints)
Decision and Company’s Duty

The Insurance Ombudsman tries to solve the case within 60 to 90 days. If both you and the company agree to mediation, the issue can be solved in 30 days.

As per the Insurance Ombudsman Rules, 2017, the insurance company must follow the Ombudsman’s order within 30 days. If not, they have to pay a fine of ₹5,000 per day. The fine goes to the Policyholders’ Protection Fund, not the customer. If the company still does not follow the order, you can go to the Consumer Forum for help.