Complete guide · India
Health insurance claim rejected? Here’s exactly what to do
A step-by-step guide to challenging a rejected or short-paid health insurance claim in India: why claims get rejected, which IRDAI rules protect you, and how to escalate from your insurer to Bima Bharosa and the free Insurance Ombudsman.
By the MediclaimSaathi team Updated 2 November 202612 min read
Quick answer
If your health insurance claim is rejected in India: (1) get the rejection in writing and note the exact clause; (2) send a written grievance to the insurer’s Grievance Redressal Officer with your counter-arguments and documents; (3) if they reject it or don’t reply within 30 days, register on IRDAI’s Bima Bharosa portal and file with the Insurance Ombudsman within one year — it is free, needs no lawyer and covers claims up to ₹50 lakh. After 60 months of continuous cover, an insurer cannot reject a claim for non-disclosure except for proven fraud.
What to do in the first 24 hours
- Ask for the rejection or settlement letter in writing, with the clause number and reason.
- Do not sign a settlement voucher that says “full and final” if you disagree with the amount.
- Collect the discharge summary, final itemised bill, doctor’s notes, test reports and your policy schedule.
- Note the date on the letter. Your deadlines run from the insurer’s replies.
- Write down your continuous coverage history, including any portability from another insurer.
10 common rejection reasons — and how to respond
Most rejections cite one of a small set of grounds. For each, here is what the insurer usually says and how policyholders typically answer it.
01Non-disclosure of a pre-existing disease
“You did not declare diabetes / hypertension / a past condition when buying the policy.”
How to respond: Check how long you have been continuously covered, including ported years. After 60 months of continuous cover the insurer cannot contest the claim for non-disclosure except for established fraud. Before that, ask the insurer to show the condition truly existed before the policy and was material to the illness claimed.
02Pre-existing disease waiting period
“The condition is excluded during the waiting period.”
How to respond: IRDAI’s 2024 rules cap the pre-existing disease waiting period at 36 months. Confirm the waiting period in your policy schedule, count your continuous tenure, and get a doctor’s note if the illness is new and unrelated.
03Room rent proportionate deduction
“You stayed in a higher room category, so all charges are reduced proportionately.”
How to respond: Proportionate deduction cannot be applied to expenses the hospital does not charge differently by room category (commonly medicines, implants and many diagnostics), or in hospitals that do not follow differential billing. Ask for the hospital’s tariff to prove which items do not vary by room.
04Consumables and “non-payable” items
“Gloves, PPE, nutrition and similar items are non-medical.”
How to respond: Compare each deduction with IRDAI’s standard list of non-payable items and with what your policy actually covers (many policies now include consumables). Doctor-prescribed clinical nutrition given as treatment is not the same as food.
05“Hospitalisation was not necessary”
“The treatment could have been done as an outpatient.”
How to respond: Ask the treating doctor for a written note explaining why admission was medically necessary, with vitals, test results and the treatment given. Day-care procedures are covered without a 24-hour stay.
06Late intimation
“You informed us after the deadline in the policy.”
How to respond: Genuine delays caused by emergencies should not defeat a valid claim. Explain the reason in writing with proof (ICU stay, emergency admission) and ask for the claim to be assessed on medical merit.
07Investigation-only admission
“The admission was only for tests.”
How to respond: Show that tests led to a diagnosis and active treatment during the stay, using the discharge summary and doctor’s notes.
08Cosmetic or excluded treatment
“This procedure is excluded as cosmetic.”
How to respond: If the procedure was needed because of illness or injury (for example reconstruction after an accident), the treating surgeon should certify the medical reason.
09Policy lapse or portability break
“The policy was not active / continuity was broken.”
How to respond: Collect renewal receipts and the portability acceptance letter. A renewal paid within the grace period keeps continuity; ported tenure counts towards waiting periods.
10Missing documents
“Claim closed for want of documents.”
How to respond: Ask in writing for the exact list, submit everything with an acknowledgement, and request reopening. A claim should not be closed without clearly telling you what is missing.
IRDAI rules that protect you
| Rule | What it means for you |
|---|---|
| 60-month moratorium | After 5 years of continuous cover, no claim can be contested for non-disclosure or misrepresentation, except established fraud. |
| Pre-existing disease waiting period | Capped at 36 months. Ported tenure counts towards it. |
| Cashless timelines | Insurers must decide cashless requests within 1 hour and final discharge authorisation within 3 hours. |
| Proportionate deduction limits | Not applicable to expenses that don’t vary by room category, or in hospitals without differential billing. |
| Insurance Ombudsman | Free, no lawyer, claims up to ₹50 lakh, file within 1 year of the insurer’s final reply. |
Your policy wording, sub-limits and exclusions still apply. Check the exact terms in your policy schedule.
The escalation path and deadlines
- 1Step 1 · Insurer’s Grievance Redressal Officer (GRO)Send a written grievance by email or the insurer’s portal with your counter-arguments and documents. Keep the acknowledgement number.
- 2Step 2 · IRDAI Bima BharosaIf the insurer rejects it or does not reply within 30 days, register a complaint at bimabharosa.irdai.gov.in or call 155255 / 1800 4254 732.
- 3Step 3 · Insurance OmbudsmanFile with the Ombudsman covering your area within one year of the insurer’s final reply. It is free, you do not need a lawyer, and hearings can be online. Claims up to ₹50 lakh.
- 4Alternative · Consumer commissionUnder the Consumer Protection Act 2019 you can also file before a consumer commission, generally within two years.
Documents to collect
- Rejection / settlement letter
- Policy schedule and wording
- Renewal receipts and portability letter
- Discharge summary
- Final itemised hospital bill
- Room tariff from the hospital
- Doctor’s prescriptions and notes
- Test and imaging reports
- Treating doctor’s certificate on medical necessity
- Proof of when you informed the insurer
What to write in your grievance letter
A strong grievance is short, factual and specific. Include:
- Policy number, claim number, patient name and dates of admission and discharge.
- The exact clause and reason the insurer cited, quoted from their letter.
- Why it does not apply, point by point, referring to the IRDAI rule or policy wording.
- The documents you are attaching as proof.
- The amount you want paid, plus interest for delay where applicable.
- A request for a written reply, and a note that you will escalate to Bima Bharosa and the Ombudsman if needed.
Get this letter written for you
Upload your rejection letter for your free check. If you want to fight it, Basic ₹49 adds 2 checks with the ready grievance letter.
Check my letter freeMistakes to avoid
- Accepting a short payment and signing “full and final settlement” without protest.
- Arguing by phone only. Always put it in writing and keep acknowledgements.
- Skipping the insurer’s grievance step. The Ombudsman expects you to complain to the insurer first.
- Missing the one-year window for the Ombudsman.
- Paying a percentage of your claim to an agent for work you can do yourself for free.
Frequently asked questions
What should I do first if my health insurance claim is rejected?+
Get the rejection or settlement letter in writing and find the exact clause cited. Then send a written grievance to the insurer’s Grievance Redressal Officer with your counter-arguments and supporting documents, and keep proof of sending.
How long does the insurer have to reply to my grievance?+
Insurers must resolve grievances within the timelines IRDAI sets. You can approach the Insurance Ombudsman if the insurer rejects your complaint or does not reply within one month (30 days).
What is the 60-month moratorium in health insurance?+
Under IRDAI’s Master Circular on Health Insurance (May 2024), after 60 months (5 years) of continuous coverage a health insurance claim cannot be contested on grounds of non-disclosure or misrepresentation, except for established fraud. Ported tenure counts.
Is the Insurance Ombudsman free, and what is the limit?+
Yes, filing is free and you do not need a lawyer. The Ombudsman can hear complaints with a claim value of up to ₹50 lakh. File within one year of the insurer’s final reply.
What is Bima Bharosa?+
Bima Bharosa is IRDAI’s online grievance portal. You can register a complaint against an insurer there and track it. Its toll-free numbers are 155255 and 1800 4254 732.
Can I go to consumer court instead?+
Yes. The Consumer Protection Act 2019 lets you file before a consumer commission, usually within two years. Many people try the free Ombudsman first because it is faster and needs no lawyer.
Can the insurer cut charges because my room was more expensive?+
Only proportionately on charges that actually depend on the room category. Items priced the same in every room, such as medicines and implants, should not be cut proportionately.
Does MediclaimSaathi take a share of the money I recover?+
No. Every account gets 1 free check. Basic ₹49 adds 2 checks with the appeal letter and Pro ₹99 adds 4 checks with the complete pack, one-time with GST included. Zero commission: the insurer pays you directly.
Guides for your exact problem
Short-paid claim · Room rent
Room rent proportionate deduction: when it’s wrong and how to get the money back
Cashless denied · Pre-authorisation
Cashless claim rejected at the hospital? What to do next
Rejected · Pre-existing disease
Claim rejected for a pre-existing disease or non-disclosure? Know your rights
Escalation · Insurance Ombudsman
How to file an Insurance Ombudsman complaint for a health claim (free)
पूरी गाइड · हिंदी
हेल्थ इंश्योरेंस क्लेम रिजेक्ट हो गया? अब क्या करें
Claim Guide · Process
Health Insurance Claim Process in India: Cashless vs Reimbursement Explained (2026)
Claim Tracking · Status Guide
Health Insurance Claim Status: How to Check & What Each Status Means
Statutory Defense · Rejection Grounds
Top Health Insurance Claim Rejection Reasons in India & How to Overturn Them
Policy Terms · Waiting Period
Health Insurance Waiting Period in India: New IRDAI 2024 Rules Explained
Regulatory Escalation · Bima Bharosa
How to File an IRDAI Complaint Online on Bima Bharosa Portal (Step by Step)
Templates · Legal Grievance
Insurance Grievance Letter Format to Insurer (Free Statutory Template)
Documentation · Checklist
Health Insurance Claim Documents Checklist: Cashless & Reimbursement (2026)
क्लेम गाइड · प्रोसेस
हेल्थ इंश्योरेंस क्लेम प्रोसेस: कैशलेस और रीइंबर्समेंट की पूरी जानकारी (2026)
क्लेम ट्रैकिंग · स्टेटस गाइड
हेल्थ इंश्योरेंस क्लेम स्टेटस कैसे चेक करें और हर स्टेटस का क्या मतलब है
कानूनी बचाव · रिजेक्शन कारण
हेल्थ इंश्योरेंस क्लेम रिजेक्ट होने के मुख्य कारण और उन्हें कैसे चुनौती दें
पॉलिसी शर्तें · वेटिंग पीरियड
हेल्थ इंश्योरेंस वेटिंग पीरियड के नए IRDAI 2024 नियम
नियामक शिकायत · बीमा भरोसा
बीमा भरोसा (Bima Bharosa) पर IRDAI में ऑनलाइन शिकायत कैसे दर्ज करें
Insurance Ombudsman · Delhi & NCR
Insurance Ombudsman Delhi: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Mumbai & MMR
Insurance Ombudsman Mumbai: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Karnataka
Insurance Ombudsman Bengaluru: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Tamil Nadu
Insurance Ombudsman Chennai: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · West Bengal & East
Insurance Ombudsman Kolkata: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Gujarat & UTs
Insurance Ombudsman Ahmedabad: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Telangana & AP
Insurance Ombudsman Hyderabad: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Maharashtra (Rest)
Insurance Ombudsman Pune: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · North India
Insurance Ombudsman Chandigarh: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Central & East UP
Insurance Ombudsman Lucknow: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Kerala & Lakshadweep
Insurance Ombudsman Kochi: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Rajasthan
Insurance Ombudsman Jaipur: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · MP & Chhattisgarh
Insurance Ombudsman Bhopal: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Odisha
Insurance Ombudsman Bhubaneswar: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Bihar & Jharkhand
Insurance Ombudsman Patna: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · North East States
Insurance Ombudsman Guwahati: Office Address, Jurisdiction & Filing Guide (2026)
Insurance Ombudsman · Western UP & Uttarakhand
Insurance Ombudsman Noida: Office Address, Jurisdiction & Filing Guide (2026)
Sources
- IRDAI — Master Circular on Health Insurance Business (May 2024)
- IRDAI Bima Bharosa grievance portal
- Council for Insurance Ombudsmen
- Insurance Ombudsman Rules, 2017 (as amended)
- Consumer Protection Act, 2019 — e-Daakhil
This guide is general information, not legal advice. Rules change; always check the current IRDAI circulars and your policy wording. MediclaimSaathi is a document-preparation platform, not a law firm, insurer or broker.