health insurance: Most people buy a health policy with the hope that they will never need to use it, and they also have the confidence that the policy will help them in case of any emergency. However, they only realize the truth when they use the policy. In many cases, policyholders’ claims are rejected even though they have been paying premiums regularly. Such rejections are a devastating blow to policyholders, especially if they rely heavily on this coverage for financial support. If you face such a situation, you should know how to get your rightful claim amount.
What to do after your health insurance claim is rejected?
If you encounter such a situation, first study the reasons for rejection and the course of action outlined in the policy. Senior Supreme Court advocate Sanjay Sen explains, “The policy itself provides a protocol for filing and pursuing a claim in the event of a rejection. Most insurance companies have established procedures for such situations.”
You can contact the Grievance Redressal Officers (GROs) of the respective health insurance company. Policyholders can also approach the relevant Ombudsman in case of a rejection, though they should first contact the insurance company.
As per experts, If an insurer has rejected an insurance claim or if the claim amount offered is less than the expenses covered under the policy, the aggrieved policyholder must first file a complaint with the respective insurer before approaching the Ombudsman. After this, the complainant can approach the Ombudsman or the Consumer Court, but not both at the same time. Is it necessary to file a fresh appeal with the health insurance company after a claim rejection?
Experts suggested that, it is not necessary to file a fresh appeal with the health insurance company after a claim rejection. She explains, “However, in cases where insurance companies have rejected the claim, informing the policyholder about the reasons for such rejection/denial, the policyholder can refile the claim after rectifying such deficiencies. But when policyholders are left with no other option, they can approach the appropriate forum.
Contact IRDAI
You can contact the Consumer Affairs Department Grievance Redressal Cell of IRDAI by calling the toll free number 155255 or 1800 4254 732 or by sending an email to complaints@irdai.gov.in.
You can also use the online portal managed by IRDAI, called the Integrated Grievance Management System (IGMS). This is a way to escalate your complaint, so it should be used only after exhausting the channels provided by the insurance company.
If, for any reason, you are unable to reach the insurance company directly, you can use IGMS; it provides a gateway for filing complaints with insurance companies.
