How to get a rejected health insurance claim reconsidered
Write to the insurer asking it to reconsider the claim, answering the exact ground in the rejection letter with evidence it did not have or did not weigh — usually a treating-doctor certificate, earlier prescriptions or the proposal form. Send it to the claims team and the Grievance Redressal Officer and keep the acknowledgement: the insurer must resolve a grievance within 14 days. If it does not reverse the rejection, take the same file to IRDAI’s Bima Bharosa and then the Insurance Ombudsman, which is free and must be approached within one year.
Step by step
Get the reason and the file in writing
Ask for the repudiation letter quoting the exact policy clause, a copy of the proposal form you signed, and the documents the decision relied on. Under IRDAI’s 2024 master circular no claim may be repudiated without the approval of the insurer’s Claims Review Committee — you can ask for confirmation that it was reviewed.
Find what answers that one ground
Non-disclosure: proof the condition was diagnosed after the policy began, or that the policy has run 60 months. Pre-existing disease: proof the waiting period has run. Not medically necessary: the treating doctor’s written reasons for admission. Documents missing: the documents, with proof they were sent.
Write the reconsideration letter
One page: your policy and claim numbers, the date and ground of rejection, why the ground does not apply, the documents attached, and what you ask for — payment of the claim amount with interest. The format is below.
Send it to the right people
Email the claims department and the Grievance Redressal Officer (the address is on the insurer’s website and policy document), or use its grievance portal. Keep the complaint number. Insurers must acknowledge at once and resolve within 14 days.
Escalate on Bima Bharosa
No reply in 14 days, or the rejection stands: register the complaint on IRDAI’s Bima Bharosa (bimabharosa.irdai.gov.in) or call 155255 / 1800-4254-732.
Go to the Insurance Ombudsman
Free, no lawyer, for claims up to ₹50 lakh. File within one year of the insurer’s final reply, or after one month without a reply. The award binds the insurer; if it is not honoured within 30 days the insurer pays ₹5,000 a day.
Consumer commission, if needed
For larger claims, compensation for harassment, or when the Ombudsman window has passed: a complaint under the Consumer Protection Act, 2019, within two years.
Reconsideration letter format
To: The Grievance Redressal Officer / Claims Department, [Insurer name and address]. Subject: Request for reconsideration of claim no. [ ] under policy no. [ ] — [patient name].
I write about the above claim, rejected on [date] on the ground of [ground as stated in the letter]. That ground does not apply, for these reasons: [one short paragraph per reason, each tied to a document].
Enclosed: [1] rejection letter, [2] policy schedule and wording, [3] treating doctor’s certificate dated [ ], [4] earlier prescriptions / investigation reports, [5] discharge summary and final bill, [6] any other document.
I request you to reconsider and settle the claim of ₹[amount], with interest for the delay as the IRDAI regulations provide, and to confirm the outcome in writing within 14 days. Yours faithfully, [name, mobile, email].
What makes a reconsideration succeed
- It answers the stated ground, not every complaint about the insurer
- Every claim in the letter is backed by an attached document
- The treating doctor’s certificate gives dates: first symptoms, first diagnosis, why admission was needed
- It quotes the rule that applies — the 60-month moratorium, the 36-month cap on pre-existing disease waiting periods, the policy clause
- It is sent in writing, to the grievance officer, with an acknowledgement kept
Time limits to keep in mind
- Insurer’s reply to a grievance: within 14 days
- Insurance Ombudsman: within one year of the insurer’s final reply
- Consumer commission: within two years of the cause of action
- Your policy may also set a time limit for submitting claim documents — act on a rejection as soon as you receive it
Rather have it reconsidered for you?
Medilock’s Claim Assistance desk writes the reconsideration, follows it through Bima Bharosa and the Ombudsman, and takes it to the consumer commission with legal partners where that is better. Legal fees are 15% + GST of what is actually settled and received by you; if the claim is finally rejected you pay nothing.
Related guides
- Claim rejected? What to do
- Common rejection reasons
- Insurance Ombudsman complaint
- IRDAI complaint (Bima Bharosa)
- Legal help for a rejected claim
- All rejected-claim guides
Can a rejected health insurance claim be reconsidered?
Yes. Write to the insurer’s claims team and Grievance Redressal Officer asking for reconsideration, answering the rejection ground with documents. Many rejections — non-disclosure, pre-existing disease, not medically necessary — are reversed at this stage or at the Ombudsman.
How long does the insurer have to reply to a reconsideration request?
A grievance must be acknowledged at once and resolved within 14 days. After that you can escalate to IRDAI’s Bima Bharosa and the Insurance Ombudsman.
Can I send new documents with a reconsideration request?
Yes, and you should. A treating-doctor certificate, earlier prescriptions showing when a condition was first diagnosed, or the proposal form often changes the decision.
Who decides a claim rejection at the insurer?
Under IRDAI’s 2024 master circular, no claim may be repudiated without the approval of the insurer’s Claims Review Committee.
What if the insurer rejects the reconsideration too?
Complain to the Insurance Ombudsman within one year — free, no lawyer needed, up to ₹50 lakh — or file in the consumer commission within two years.
रिजेक्ट क्लेम पर दोबारा विचार (reconsideration) कैसे करवाएँ?
बीमा कंपनी के ग्रीवेंस ऑफ़िसर को लिखित में रिजेक्शन का कारण और उसका जवाब दस्तावेज़ों के साथ भेजें। 14 दिन में हल न हो तो बीमा भरोसा और फिर बीमा लोकपाल के पास जाएँ।