Your Claim Was Rejected. The Next Step Is Free, and Most People Never Take It.

A claim rejection arrives written in the voice of a final decision: a clause number, a conclusion, no invitation to discuss. It is not final. It is one party’s position on a contract, and there is a free adjudicator whose entire function is to review exactly that.

First, get the reason in writing

Everything downstream depends on knowing the precise ground. Ask for the rejection in writing, quoting the specific policy clause relied on and the facts said to bring your claim within it. A rejection that says only “not payable as per terms” is not a reasoned rejection, and asking for the clause is both your entitlement and, frequently, the point at which a weak rejection is reconsidered.

Under IRDAI’s Health Master Circular of 29 May 2024, a health claim repudiation requires sign-off by the insurer’s Claims Review Committee — so a rejection is meant to have passed a defined internal gate, not merely a processor’s judgement. Asking whether it did is a reasonable question.

The sequence

1. Grievance to the insurer. Every insurer has a designated grievance officer, and this step is a precondition for what follows.
2. IRDAI’s Bima Bharosa grievance system, where the insurer’s response is unsatisfactory.
3. The Insurance Ombudsman, which is free, requires no lawyer, and can pass an award binding on the insurer within its pecuniary limits.

Where an Ombudsman award is made and the insurer does not comply, IRDAI’s Health Master Circular provides for a charge of Rs 5,000 per day against the insurer — a provision that exists precisely because awards were being ignored.

What actually decides these complaints

The frequent grounds of rejection have well-worn answers, and knowing which one you are arguing about changes what evidence matters.

• Pre-existing disease. The question is what was known and diagnosed before the policy, not what a doctor later infers might have been developing. Treatment records and their dates decide it.
• Non-disclosure. The insurer must show the undisclosed fact was material. Note also the moratorium: after 60 months of continuous cover, a health claim cannot be denied on non-disclosure or misrepresentation, except for established fraud.
• Waiting period. Turns on the policy’s continuous-cover history, including portability from an earlier insurer — which carries accrued credits with it.
• “Not medically necessary”. The treating doctor’s written justification is the evidence that answers it.

Building the file

Ombudsman complaints are decided on documents. Assemble: the policy schedule and full wording, the proposal form you actually signed, the complete hospital record and discharge summary, the treating doctor’s note, every bill, the claim form, the rejection letter with its clause, and your grievance correspondence with dates.

The proposal form is worth singling out. A significant share of non-disclosure rejections concern forms filled in by an intermediary and signed without being read. Obtaining the form the insurer holds — and comparing it to what you actually told them — is often where the complaint is won or lost.

The reason to bother

Rejections are not uniformly wrong, and some are correct. But the process is asymmetric by design: the insurer has the wording, the medical opinion and the file, and it is relying on the policyholder concluding that a letter on letterhead is the end of the matter. The escalation costs nothing but the assembly of documents you already have.

How to use this page

This page describes published regulatory frameworks and the official channels that go with them. It is general information, not advice on your particular case, and the documents governing your own account, loan or policy control the specifics.

Every route here is free

No agent, consultant or recovery service can obtain an outcome you cannot obtain yourself, and none is required at any stage. Oquilia takes no fee from readers, offers no recovery service, and refers no one to any legal practice.

Escalation, in order

The entity’s own grievance channel first. Then, for banks, NBFCs and payment systems, the RBI Ombudsman at cms.rbi.org.in; for insurers, the Insurance Ombudsman; for online financial fraud, cybercrime.gov.in or 1930.