Your health insurance claim was rejected. Here's what to do next.

Your insurer must provide a written rejection with a specific reason and the policy clause cited. Read the letter and note: - The exact reason for rejection - The clause number cited - Any reference to a waiting period, exclusion, or documentation gap If the letter is vague or cites no clause, that itself is a ground for challenge under IRDAI Circular on Claims Settlement.

Get your policy document and locate the clause cited in the rejection letter. Read it carefully — in full, not just the part the insurer highlighted. Common situations where rejections are wrongful: - The clause was misinterpreted or applied out of context - The exclusion applied to a different type of treatment - The waiting period had already elapsed - The condition doesn't actually meet the definition of "pre-existing disease" under IRDAI guidelines

Before going to the Ombudsman, you must give your insurer a chance to resolve the complaint. Email the insurer's Grievance Redressal Officer (GRO) with: - A formal complaint letter citing the specific clause misapplied - Supporting documents (policy, rejection letter, hospital bills, discharge summary) - A request for resolution within 15 working days If unresolved within 30 days, you can escalate to the Ombudsman.

The Insurance Ombudsman is a free, independent grievance redressal mechanism under the Government of India. File online at cioins.co.in. The Ombudsman can award up to ₹30 lakhs. The average resolution time is 3 months. You are eligible to approach the Ombudsman if: - The claim amount is up to ₹50 lakhs (for health insurance) - You filed a complaint with the insurer and it was not resolved to your satisfaction - The rejection is within 3 years

IRDAI's Health Insurance Regulations require: - Claims to be decided within 30 days of receiving all documents - Cashless authorisation decisions within 1 hour (emergency) or 3 hours (planned) - Written rejection with clause citation — oral rejections are not valid - Access to grievance redressal at no cost If your insurer has violated any of these, state this clearly in your complaint.