Legal help for a rejected health insurance claim

Medilock takes up rejected, delayed and short-paid health insurance claims for individuals and families across India — the representation to the insurer, the legal notice, the IRDAI complaint, the Insurance Ombudsman and, where it takes that, the consumer commission. Legal fees are 15% + GST of what is actually settled and received by you. If the claim is finally rejected, you pay nothing.

Step by step

1. Tell us what happened

   Your mobile number, a few details and the reason the claim is stuck. It takes two minutes on medilock.in.

2. Send the papers

   Policy copy or e-card, the rejection or query letter, and your medical and billing documents. Upload them from your phone.

3. We review the rejection

   Our desk reads the stated ground against your policy wording, the proposal form and the IRDAI rules, and tells you plainly whether it is contestable and what it is worth.

4. We take it up

   A written representation and, where useful, a legal notice to the insurer; escalation on Bima Bharosa; the Insurance Ombudsman complaint and hearing; and the consumer commission through our legal partners when that is the better forum.

5. You track every step

   Check the stage any time with your mobile number, and log in for messages from the desk and any document requested.

6. You pay only on success

   When the insurer pays and the money reaches you, our invoice is 15% + GST of that amount. A claim that is finally rejected costs you nothing.

Claims we take up

• Rejected for non-disclosure or a pre-existing disease
• Rejected as "not medically necessary", "OPD treatment" or "day care not covered"
• Rejected for a waiting period or a policy exclusion
• Short-paid: room-rent proportionate deduction, co-pay, "reasonable and customary" cuts, non-payable items
• Delayed for months with repeated queries
• Cashless denied at admission or at discharge
• Reimbursement claims closed for "documents not submitted"

Why legal help changes the outcome

Most rejected claims are lost on paper, not on merit. The insurer states one ground; the reply has to answer that ground, with the right document, under the right rule — the 60-month moratorium, the 36-month cap on pre-existing disease waiting periods, the treating doctor's certificate, the proposal form the agent filled in. A reply that argues everything usually wins nothing.

We also choose the forum. The Insurance Ombudsman is free, quick and binding on the insurer for claims up to ₹50 lakh. The consumer commission can award compensation and costs beyond the claim and has no upper limit. A legal notice sometimes settles the matter before either is needed.

Ombudsman or consumer court — how we decide

• Insurance Ombudsman: no fee, no lawyer needed, decision usually within about three months of a complete complaint, award binding on the insurer. Best for most individual claims up to ₹50 lakh.
• Consumer commission: compensation for harassment and litigation costs on top of the claim, no upper limit, but slower. Better where the insurer acted in bad faith, the amount is large, or the Ombudsman route is closed.
• Legal notice: a formal demand that often moves a stuck claim, and the usual first step before the consumer commission.

What you need to start

• Policy schedule or e-card, and the policy wording if you have it
• The rejection, repudiation or query letter
• Discharge summary, investigation reports, prescriptions and final bills
• Any letters or emails with the insurer or TPA
• If you have it: the proposal form, and your earlier policies if you ported

Where we work

Across India, online. Mumbai, Delhi NCR, Pune, Bengaluru, Hyderabad, Chennai, Kolkata, Ahmedabad, Jaipur, Lucknow, Indore, Nagpur and everywhere else — every Insurance Ombudsman office accepts online complaints, and consumer complaints are filed online too.

What it costs

Legal fees: 15% + GST of the amount actually settled and received by you, payable after you are paid. If your claim is finally rejected, you pay us nothing. Hospitals with pending or short-paid cashless claims use Medilock Cashless Recovery instead.

Related guides

• Claim rejected? What to do
• Insurance Ombudsman complaint
• Consumer court for a rejected claim
• Legal notice to an insurer
• Common rejection reasons
• Rejected for pre-existing disease / non-disclosure
• All rejected-claim guides

Do I need a lawyer for a rejected health insurance claim?

Not legally — the grievance officer, IRDAI and the Insurance Ombudsman are designed for policyholders to use directly. People use legal help because the outcome turns on answering the rejection ground precisely, with the right documents and rules, and on choosing the right forum.

How much does legal help for a rejected claim cost at Medilock?

Legal fees are 15% + GST of the amount actually settled and received by you. If the claim is finally rejected, you pay nothing.

How long does it take to get a rejected claim paid?

A representation can settle in weeks. An Ombudsman complaint is usually decided within about three months of being complete. A consumer complaint takes longer — often months to a couple of years.

Can I go to consumer court after the Ombudsman?

If you do not accept the Ombudsman's award you can still approach the consumer commission, within two years of the cause of action. The award binds the insurer, not you.

Can a claim rejected for non-disclosure be reversed?

Often. If the condition was diagnosed after the policy began, if the only evidence is a remark in a discharge summary, or if the policy has run 60 months continuously, the rejection is open to challenge.

Do you handle claims outside Mumbai?

Yes, anywhere in India. The work is done online and every Ombudsman office accepts complaints online.

Which claims will you not take?

Ones we do not think will succeed. We tell you that at the start, because there is no point either of us spending months on a file that cannot win.