Rejected · Medical necessity

Claim rejected as “not medically necessary”? How to prove your hospitalisation was needed

Insurers sometimes say a patient could have been treated at home or as an outpatient. That is a medical question, and your doctor’s records are the best answer.

By the MediclaimSaathi team Updated 8 November 20266 min read

What the insurer is saying

These rejections often involve conditions like fever, infections, dengue or pain, where an insurer says admission for observation was not needed, or that only diagnostics were done.

The treating doctor, who examined the patient, is best placed to explain why admission was needed at that time.

Evidence that helps

• A signed certificate from the treating doctor on why admission was necessary.
• Admission notes with symptoms, vitals and examination findings at the time.
• Investigation reports (blood counts, scans) that show severity.
• The treatment chart showing in-patient treatment, such as IV fluids or monitoring.
• The discharge summary and the day-by-day progress notes.

How to challenge it

1. 1Ask for the insurer’s reasoningGet the rejection letter and, if possible, the medical opinion it is based on.
2. 2Get the doctor’s certificateAsk for a certificate that explains why admission, not outpatient care, was needed.
3. 3Answer each pointMatch your evidence to each point the insurer made.
4. 4Send a grievanceWrite to the Grievance Redressal Officer with the file and the amount you want.
5. 5EscalateAfter 30 days of silence or a rejection, use Bima Bharosa and the Insurance Ombudsman within one year.

Frequently asked questions