My Health Claim is Rejected: What to Do Now?

What to Do When Your Health Insurance Claim is Rejected in India

“Is your health insurance claim unexpectedly rejected? Don't worry —here’s a clear step-by-step guide to help you get things back on track.”

Receiving a health insurance claim rejection during a medical emergency can be distressing. Such claim repudiation might be due to multiple reasons or shortfalls. This in-depth guide will help you in understanding how to deal with such challenging situation. 

Step 1: Understanding the Reason for Rejection

First, find out the reason for your health insurance claim rejection in writing. Insurance companies are obliged by IRDAI to give the reason for rejection in writing. Get the rejection letter and get it explained by the officials or your agent. 

Step 2: Know the Role of the TPA

Role of TPA is to process the claim but it can't repudiate a claim. It will send its observations, assessment, documents and recommendations for the insurer to take a decision on rejection and communicate the same to the customer. 

If you are not sure whether TPA or insurer has repudiated the claim, take clarification.

Step 3: Gather and Resubmit Missing Documents

After you receive the claim rejection / repudiation letter by insurer, analyze what they are saying. If any document is not submitted, get the necessary document and submit the same for reopening and processing the claim. 

Step 4: Appeal the Rejection With Proper Justification

If the cause of rejection is something else, understand the reason completely. You can ask insurance company office or your agent / broker to explain what the reason is. 

If you are satisfied about the rejection of claim, based on the reasons mentioned by insurer, get the coverage increased or switch to better policies or insurer for better coverage. 

Step 5: Escalate to Grievance Redressal Channels

If you are not satisfied with the reason for rejection and you are sure that you are still entitled to get the claim, you may request the insurer to reconsider / reopen the rejected insurance claim. Explain them why you think you deserve the claim to be honored. Avoid vague explanations—clearly shoot to the rejection points individually, cite policy clauses or medical records to support your case.

Once your request for reopening is not considered, you may reach grievance department of the insurance company, usually through official website. 

Step 6: Approach the Insurance Ombudsman or Consumer Court

If there is no reply to that also, you can consider giving complaint with Insurance Ombudsman India, which is a forum to submit the grievances. Or you can consider giving complaint with IRDA grievances portal. This portal is user friendly and you can easily understand how to file complaint with IRDAI.

Even after that, if you are not satisfied with the outcome, you have the option to go Consumer Forum. For this, you might need services of an advocate who can guide you in how to appeal claim in law forums. 

  

While you request to review the claim, you are obliged to maintain all communication in writing and recorded. Keep all the correspondences, policy number, claim ID and photocopies of all submitted documents. Where ever possible, get acknowledgement of submitted documents or send through mail or through registered post. Ensure to adhere to timelines of the claim procedures. 

    Follow this action plan: 

• Understand the reason for rejection
• Resubmit missing documents / shortfalls 
• Appeal with sufficient proof 
• Escalate through official channels 
• File complaint with Ombudsman or IRDAI 
• Seek legal action if necessary

💬 FAQs on "How to Appeal Rejected Insurance Claim":

❓Can I reapply after my health insurance claim is rejected?

Yes, you can. If the claim rejection was due to incorrect or missing documentation, you can request for reopening claim by submitting the required.

❓How do I complain to the IRDAI about claim rejection?

Try to approach insurer through official channels, if you are not satisfied about the response, you can file a complaint on the IRDAI’s portal of Integrated Grievance Management System (IGMS): https://igms.irda.gov.in

❓What if my health insurance claim is unfairly denied?

You have the option to escalate to the insurer’s grievance redressal department, the Insurance Ombudsman, or the legal platforms like Consumer Court if needed.

Summary: 

Don’t give up if your insurance claim is denied. Follow the above steps and escalate as required. Share this guide with your loved ones who might be facing the same issue, or check our post on ‘Top Mistakes to Avoid During Health Insurance Claims’ for more insights.