Reimbursement claim rejected? How to get it paid

When a reimbursement claim is rejected, the insurer has to give a specific reason. Most reasons — late submission, missing documents, non-disclosure, "not medically necessary" — can be answered with documents. Write to the grievance officer first; if that fails, the Insurance Ombudsman decides free of charge within about three months of a complete complaint.

Step by step

  1. Check what was actually said

    Full rejection, partial payment, or a "closed" claim waiting for documents? A closed claim is reopened by sending the documents asked for.

  2. Answer late submission with the reason

    Delay in submitting a reimbursement claim is condoned where there is a genuine reason — the insurer must consider it rather than reject only on time.

  3. Send what was missing, in one go

    Original bills and receipts, discharge summary, reports, prescriptions with pharmacy bills, and the claim form signed by the hospital.

  4. Grievance officer, then Bima Bharosa

    Reply in writing to the Grievance Redressal Officer (14 days), then register on Bima Bharosa if there is no reply.

  5. Ombudsman or consumer commission

    Within one year of the insurer's final reply for the Ombudsman, within two years for the consumer commission.

Partly paid? Ask for the deduction sheet

Ask for the claim settlement or deduction sheet line by line. Room-rent proportionate deduction, "non-payable items" and package rates are where most of the money goes — and several of those deductions are not allowed on pharmacy, implants, consumables or diagnostics.

Related guides

My reimbursement claim was rejected for late submission. Can I still claim?

Yes, if there was a genuine reason for the delay. Explain it in writing to the grievance officer with proof; the Ombudsman routinely accepts delays with a reason.

What if the insurer says documents are missing?

Send exactly what is listed, together, with a covering letter quoting the claim number, and keep the acknowledgement.