Health insurance claim rejected? Here is what to do.

A rejection is not final. Find the exact ground in the rejection letter, collect the policy, the proposal form, a treating-doctor certificate and the hospital file, and write to the insurer's Grievance Redressal Officer. If that does not reverse it, the Insurance Ombudsman hears the complaint free of charge within one year of the insurer's final reply, and its award binds the insurer. Rejections on non-disclosure, pre-existing disease and "not medically necessary" are regularly reversed this way.

Step by step

  1. Read the rejection letter for the ground

    Every repudiation letter names a reason: non-disclosure, pre-existing disease, waiting period, policy exclusion, not medically necessary, or late intimation. Write it down. Every step after this answers that one ground.

  2. Collect four documents

    The policy wording with its exclusion list, the proposal form you signed (ask the insurer for a copy — you are entitled to it), a certificate from your treating doctor stating when the condition was first diagnosed, and the complete hospital file: discharge summary, investigations and bills.

  3. Check the moratorium and waiting periods

    Under IRDAI's 2024 health insurance master circular, after 60 months of continuous cover an insurer cannot contest a claim on non-disclosure unless it proves fraud, and the pre-existing disease waiting period can be no longer than 36 months. Count your years of cover, including portability and renewals.

  4. Write to the insurer's Grievance Redressal Officer

    Answer the stated ground with your documents, in writing, and keep the acknowledgement. Insurers must acknowledge a grievance immediately and resolve it within 14 days.

  5. Escalate to IRDAI on Bima Bharosa

    If there is no reply in 14 days or the reply does not help, register the complaint on Bima Bharosa (bimabharosa.irdai.gov.in), call 155255 or 1800-4254-732, or email complaints@irdai.gov.in. The complaint is logged and tracked by the regulator.

  6. Go to the Insurance Ombudsman within one year

    Free, no lawyer needed, for compensation up to ₹50 lakh. File within one year of the insurer's final reply — or after one month if the insurer has not replied. The Ombudsman passes an award within three months of receiving everything, and the insurer must comply within 30 days.

  7. Consumer Commission if needed

    A complaint for deficiency in service under the Consumer Protection Act, 2019, filed within two years. Most health insurance complaints are heard by the District Commission, and can be filed online on e-Jagriti.

Which rejections are most often reversed

Non-disclosure where the condition was diagnosed after the policy began, or where the only evidence is a line in a discharge summary written from what the patient said at admission. Pre-existing disease where the waiting period has already run. "Not medically necessary" where the treating doctor can explain in writing why admission was required. Late intimation where the delay did not actually prevent the insurer from assessing the claim.

Ombudsman or consumer court?

Start with the Ombudsman: it is free, faster and needs no lawyer, and its award binds the insurer. Choose the consumer commission when the claim is above ₹50 lakh, when you also want substantial compensation for harassment and costs, or when the one-year Ombudsman window has passed. You cannot run both at once on the same matter.

If you are a hospital

A cashless claim that is approved but never paid, repudiated after discharge, short-paid after a tariff deduction or closed without intimation is recoverable through the same escalation route, with the TPA in the chain. Medilock's Cashless Recovery desk takes these up for hospitals.

If you would rather not run it yourself

Medilock Claim Assistance takes the file up with the insurer for you, with recovery and legal support through the grievance, Ombudsman and consumer court routes. 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

What should I do first if my health insurance claim is rejected?

Read the rejection letter for the exact ground and ask the insurer in writing for a copy of your proposal form. Most successful challenges answer the stated ground with four documents: the policy wording, the proposal form, a treating-doctor certificate and the hospital file.

How long do I have to challenge a rejected claim?

Write to the insurer's grievance officer as soon as possible. The Insurance Ombudsman must be approached within one year of the insurer's final reply, and a consumer complaint within two years.

Is the Insurance Ombudsman free?

Yes. There is no fee and you do not need a lawyer. The Ombudsman can award compensation up to ₹50 lakh and its award binds the insurer.

Can an insurer reject my claim for non-disclosure after five years?

Not under IRDAI's 2024 health insurance master circular. After 60 months of continuous cover the policy cannot be contested on non-disclosure or misrepresentation, except for proven fraud.

Can I get legal help for a rejected health insurance claim?

Yes. Medilock reviews the rejection, tells you whether it is contestable and takes it up with the insurer, the Ombudsman or the consumer commission. You pay 15% + GST only on what is actually settled; nothing if the claim is finally rejected.