Health insurance claim rejected or cut in India, what to do next

Why claims get rejected or cut

A rejection means the insurer pays nothing. A deduction means it pays part. These are reasons an insurer may give, in plain words:

• Waiting period not over. Under IRDAI's 2024 product regulations, a disclosed pre-existing disease, or a disease or treatment your policy lists, can be excluded for up to 36 months.
• Non-disclosure. The insurer says a condition was not declared when you bought the policy. After 60 months of continuous cover, it cannot contest a claim on this ground except for established fraud.
• Exclusion. The treatment is outside what the policy covers.
• Limits. A sub-limit, the room rent limit or a proportionate deduction cut the amount.
• Non-payable items. Charges such as toiletries or attendant fees were removed.
• Cost sharing. A co-payment or deductible was applied.

Your rights before you complain

The 2024 master circulars give you these protections:

• No claim can be rejected without approval of the insurer's Product Management Committee or its Claims Review Committee.
• A rejection or partial cut must be conveyed with full details and a reference to the specific policy terms.
• No claim shall be rejected or closed for want of documents or for delayed intimation.
• A TPA cannot reject a claim on its own. Under IRDAI's 2016 TPA regulations, a rejection must come from the insurer, directly to you.

The escalation steps, in order

1. ✉️Step 1The insurer's grievance officer
2. 🖥️Step 2IRDAI's Bima Bharosa portal
3. ⚖️Step 3The Insurance Ombudsman

Step 1. The insurer's grievance officer

Complain in writing to the insurer. You can go to a branch, write a letter or email, use the insurer's website or call its call centre. The contact details of the grievance officer are in your Customer Information Sheet and policy. The insurer must acknowledge your complaint immediately and resolve it within 14 days. Its reply must include the contact details of the Insurance Ombudsman.

Step 2. IRDAI's Bima Bharosa portal

You can register the complaint online at bimabharosa.irdai.gov.in and track it there. IRDAI's call centre is on 155255 or 1800 425 4732, from 8 am to 8 pm, Monday to Saturday. This step is optional. Bima Bharosa does not ask for payment of any kind, so ignore anyone who asks for money to speed up a claim.

Step 3. The Insurance Ombudsman

Under Rule 14 of the Insurance Ombudsman Rules, 2017, you can go to the Ombudsman once you have complained to the insurer in writing and it has rejected the complaint, not replied within one month, or replied in a way you do not accept. The Ombudsman hears disputes about partial or total repudiation of claims, and can award up to ₹50 lakh, the cap set by the November 2023 amendment to the Rules.

• File within one year of the insurer's reply, or within one year of the one-month wait running out.
• The same matter must not be pending before a court, consumer forum or arbitrator.
• File online at cioins.co.in/Complaint/Online, by email, by post or in person.
• In Delhi NCR, the Delhi office covers Delhi, Gurugram, Faridabad, Sonepat and Bahadurgarh. The Noida office covers Gautam Buddh Nagar and Ghaziabad, among other districts.
• You can file where the insurer's office is or where you live.

The time limits

1. 14 daysInsurer resolves your complaint
2. 1 month after it received your complaintEarliest point for the Ombudsman if the insurer is silent
3. 1 yearLast date to file with the Ombudsman
4. 3 months after receiving all requirementsOmbudsman passes award
5. 30 daysInsurer complies with the award

The penalty in the September 2024 policyholder master circular is ₹5,000 for each day of delay. For example, an insurer 10 days late would owe ₹50,000 on top of the award and interest.

What to keep in writing

• The policy, schedule and Customer Information Sheet.
• The pre-authorisation request, approval, denial or enhancement letters.
• The final bill, discharge summary and payment receipts.
• The settlement or rejection letter, with the clause it cites.
• Your complaint to the insurer, its date and the acknowledgement number.
• Every reply, and the Bima Bharosa complaint number if you used it.

Have a hospital stay coming up? Send your policy on WhatsApp and a person checks it for you.