Your health insurance claim was rejected. What to do next.

A rejection letter from your health insurer feels final. Often it is not the last word. The rules give you clear protections, real deadlines and a free government-appointed forum. This guide explains what the rejection actually means and the routes open to you.

First, check what actually happened

"Rejected" covers four different situations, and the right response depends on which one is yours.

1. Cashless refused at the hospital - The insurer declined pre-authorisation before or during treatment, or said it could not offer cashless and would reimburse instead. This is not a claim rejection. You can pay the hospital and file a reimbursement claim afterwards, which the insurer must then decide on the policy's terms.
2. Claim rejected after discharge - A formal repudiation letter stating the claim will not be paid. Most of this guide is written for this situation.
3. Claim only partly paid - The insurer paid less than the bills, citing deductions, sub-limits or room-rent rules. The same routes apply to the unpaid part.
4. No decision at all - Silence beyond the allowed timeline is itself something you can complain about, and the timelines carry a cost for the insurer.

Read the rejection letter slowly

Insurers are not allowed to reject a claim on a vague feeling. A repudiation needs the approval of a committee (the Claims Review Committee) and evidence the insurer can defend, and every rejection, repudiation or partial disallowance must come to you with full reasons referencing the exact policy clause. The insurer's resolution letter must also carry the contact details of the Insurance Ombudsman for your region. If yours is missing any of this, asking for it in writing is your first move.

The common reasons, what they usually mean, and what to ask for. Whatever the reason, the point is the same: pin the insurer to the exact policy clause and the evidence behind it.

• Pre-existing disease not disclosed: the insurer says a condition existed before the policy and was never declared. Ask for the exact proposal-form answer it relied on, and check it against what you actually wrote.
• Waiting periods: a new policy has an initial wait for illnesses (accidents are excepted), some listed diseases have their own wait, and a pre-existing disease becomes payable only after the wait stated in your policy - current regulations cap that one at thirty-six months of continuous coverage. Ask which wait was applied and from which date it was counted.
• Exclusion: the treatment itself sits outside the policy's cover. Ask for the exact exclusion clause number.
• Could have been treated without admission: check whether your policy covers OPD, inpatient or day-care treatment, and on what terms. An admission's duration alone does not establish medical necessity or cover. If the insurer says admission was not needed, ask for the exact clause it relied on and check the treating doctor's records against it. (Nobody should stay in hospital just to make a claim payable; the answer has to come from the policy wording and the medical records.)
• Cashless refused, reimbursement suggested: the hospital may be outside the insurer's network, or the pre-authorisation was declined on the spot. This is not a rejection of the claim itself. You can pay and file for reimbursement, which the insurer must then decide on the policy's terms - ask for the reason for the cashless refusal in writing.
• Documents or late intimation: on their own, missing papers or late intimation are not a valid ground to reject or close a claim under the 2024 rules.
• Deductions: sub-limits, room-rent proportionate cuts, co-payment, or items classed as non-medical. The claim is partly paid, not refused; the same routes apply to the unpaid part. Sometimes correct, sometimes misapplied - ask for a line-by-line deduction sheet.
• Policy not in force: check whether the treatment date falls within a paid-up, in-force period - a premium unpaid beyond the grace period can mean the policy had lapsed, or was renewed on changed terms. Match the premium receipts and due dates against the treatment date before anything else.
• Hospital not acceptable: if the insurer cites an excluded or non-eligible hospital, ask for the applicable policy clause, its current excluded-provider list, and whether any emergency exception applies. Check your actual policy rather than assuming a non-network hospital means no cover.

Know the rules that protect you

From IRDAI's Master Circular on Protection of Policyholders' Interests, 2024, and the current health insurance regulations:

• A claim cannot be rejected or closed only for want of documents or for delayed intimation.
• Cashless requests must be decided within one hour, and final discharge authorisation within three hours. If a discharge delay costs you extra, the insurer bears that cost.
• Reimbursement claims must be settled within fifteen days of submission.
• If the insurer misses these claim timelines, the rules entitle you to interest at the bank rate plus 2 percent, from the claim intimation until payment, payable by the insurer on its own.
• After sixty months of continuous coverage (time on a ported policy counts), the insurer can no longer contest a claim on grounds of non-disclosure or misrepresentation, except proven fraud. The protection covers only these grounds; cover limits, exclusions and waiting periods still apply as written. This is the five-year moratorium.

Get your paperwork in one place

• The full policy document, every page, and your signed proposal form
• The rejection or settlement letter, and every email and SMS exchanged
• Claim form, hospital bills and receipts, and the discharge summary
• Prescriptions, test and scan reports, and operation or implant records where relevant
• A simple date-wise note of what happened and when

Keep copies of everything you submit, and take a written or email acknowledgment for every complaint you file.

The routes open to you

Start by complaining to your insurer in writing - the Ombudsman requires it, and the other routes have their own eligibility rules. Here is what each one does.

1. Start with the insurer's grievance officer - Write a formal complaint to the Grievance Redressal Officer (every insurer lists one). Attach your documents and take an acknowledgment with the date. The insurer should resolve it within fifteen days.
2. IRDAI's Bima Bharosa - The regulator's own complaint channel, available whenever the insurer is slow or its answer unsatisfactory: register at bimabharosa.irdai.gov.in, call 155255, or email [email protected]. You get a token number, can track the complaint, and it lands directly in the insurer's system.
3. The Insurance Ombudsman - A free decision forum, no lawyer needed. It needs your written complaint to the insurer first: you can file once the insurer has rejected it, replied unsatisfactorily or not replied within one month, and normally within one year of that point (the Ombudsman can excuse delay in deserving cases). Amounts up to 50 lakh rupees, online at cioins.co.in. If mediation does not settle it, the Ombudsman passes a reasoned award that is binding on the insurer, which then has thirty days to comply; the 2024 master circular adds a 5,000-rupee penalty for each day of delay, unless the insurer appeals.
4. A consumer commission - The legal route, an alternative rather than a next step. File within two years of the cause of action (usually the rejection, though the counting can be nuanced and a late filing is excused only for sufficient cause, so take professional advice if the timing is not clearly safe). Which commission hears it depends on the consideration paid: district up to 50 lakh rupees, state up to 2 crore, national above that. Filing is online, on e-Jagriti.

Choosing between routes - The Ombudsman cannot take up a matter on which proceedings are pending before, or have already been decided by, a court, consumer commission or arbitrator. If the Ombudsman settles your complaint through mediation, you will be asked to accept the settlement in writing as full and final. Before accepting a settlement, or choosing between proceedings, take legal advice.

Two honest notes

Nobody honest can promise that your claim will be settled. Be careful of anyone who guarantees an outcome. The strength of a case comes from the policy wording, the facts and the paperwork, not from who files the complaint.

And some rejections are correct. If the treatment was a clear exclusion, or the proposal form hid something material, be prepared for the answer to stay no. What these routes give you either way is a fair, rules-based hearing of your case.

If you want a second pair of eyes

If you are staring at a rejection letter and want a careful second read of what the clause says, what the rules allow and which route fits, you can start a conversation below. No promises, just a plain reading and clear next steps.