My health insurance claim is rejected. Can I still get paid?

Often, yes. A rejection letter is the insurer's first answer, not the last word. Many rejections — non-disclosure, pre-existing disease, "not medically necessary", late intimation — are reversed once each ground is answered in writing with the right document. You have one year to take the claim to the Insurance Ombudsman, free of charge, and two years for the consumer commission.

Step by step

1. Do not argue on the phone

   Calls to the helpline leave no record. Everything from now on goes in writing — email or the insurer's grievance portal — and you keep every acknowledgement number.

2. Find the exact ground

   The rejection letter quotes a clause or a reason. Copy the exact words. Your reply answers that ground and nothing else.

3. Ask for your proposal form and the claim file

   You are entitled to a copy of the proposal form you signed and the documents the insurer relied on. Many non-disclosure rejections fall apart once the proposal form is read.

4. Get one letter from your doctor

   A short certificate from the treating doctor: when the illness was first diagnosed, and why hospitalisation was needed. This single letter reverses more rejections than anything else.

5. Write to the grievance officer

   Send the reply with the documents to the insurer's Grievance Redressal Officer. The insurer must resolve it within 14 days.

6. Escalate if it is not reversed

   Bima Bharosa (IRDAI), then the Insurance Ombudsman within one year, or the consumer commission within two years.

Rejections that are most often reversed

• Non-disclosure of an illness that was diagnosed after the policy started
• Pre-existing disease when the waiting period (36 months at most) has already passed
• Any non-disclosure ground after 60 months of continuous cover (the moratorium)
• "Not medically necessary" or "could have been treated as OPD" when the doctor's notes say otherwise
• Late intimation or late documents, when the delay has a reason
• An exclusion read too widely — exclusions are read strictly against the insurer

What the insurer has to give you

The specific reason for the rejection in writing, the clause relied on, and a copy of your proposal form on request. A claim cannot be repudiated without the insurer's Claims Review Committee looking at it. If a letter only says "not payable as per policy terms", ask in writing for the exact clause.

Mediclaim, cashless, reimbursement — does it matter?

No. Mediclaim is simply an older name for a hospitalisation policy. Whether the claim was cashless or reimbursement, rejected in full or paid in part, the same route applies: grievance officer, Bima Bharosa, Insurance Ombudsman, consumer commission.

Want us to look at it?

Send the rejection letter and the policy to Medilock. Our desk tells you, free, whether the rejection is contestable. If we take it up, the fee is 15% + GST of what is actually settled and received by you — nothing if the claim is finally rejected.

Related guides

• Claim rejected? What to do
• Common rejection reasons
• Grievance letter to the insurer — format
• Insurance Ombudsman complaint
• Time limits — grievance, Ombudsman, consumer court
• All rejected-claim guides

My claim is rejected. Is it final?

No. The insurer's rejection can be challenged with its Grievance Redressal Officer, then IRDAI's Bima Bharosa portal, the Insurance Ombudsman (free, up to ₹50 lakh) and the consumer commission.

How do I ask the insurer to reconsider a rejected claim?

Write to the Grievance Redressal Officer, quote the rejection ground, answer it point by point and attach your documents: the policy wording, your proposal form, a treating-doctor certificate and the hospital file.

Can I complain about a rejected mediclaim online?

Yes. On the insurer's grievance portal, on Bima Bharosa (bimabharosa.irdai.gov.in), and with the Insurance Ombudsman at cioins.co.in.

How much does it cost to challenge a rejected claim?

The grievance officer, Bima Bharosa and the Insurance Ombudsman are free. Consumer commission fees are nil where the premium paid is up to ₹5 lakh. If Medilock takes it up, you pay 15% + GST only of what is actually settled.