Reviewed on 2026-08-02 by Dr. Shrawan Kumar Pathak.
Quick Reply: Your health insurer rejected your claim or denied cashless? You have four escalation steps: (1) complain to the insurer's grievance officer (15 days), (2) file online with IRDAI's IGMS portal, (3) approach the Insurance Ombudsman (free, up to ₹50 lakh), and (4) file a consumer complaint. If your insurer is government-owned (LIC, New India Assurance, etc.), you can also file an RTI to get the exact reason for rejection.
Your health insurance claim was rejected. The hospital is asking for money. You are worried and angry. This guide tells you exactly what to do, step by step, in plain language.
—
Before you fight, understand the reason. Insurers must give you a written rejection letter stating the exact clause and reason. Common reasons:
| Reason | What it means | Is it fair? |
| — | — | — |
| Pre-existing disease (PED) | You had the condition before buying the policy | Only fair if the PED was declared AND the waiting period (usually 2-4 years) has not passed |
| Non-disclosure | You did not tell the insurer about a past illness | The insurer must prove you knew about the condition and hid it. See our pre-existing disease appeal guide |
| Policy exclusions | The treatment is not covered (e.g., cosmetic, experimental) | Check the exclusion list carefully — vague clauses are read in YOUR favour per Supreme Court rulings. See ambiguity favours the insured |
| Room rent limit breached | You chose a room above your policy's cap | Insurers then proportionately deduct the ENTIRE bill. See room rent cap guide |
| Cashless denied | The hospital is not on the insurer's cashless network, or TPA did not approve | The insurer MUST respond to a cashless request within 3 hours (IRDAI guideline). See cashless delay guide |
| Incomplete documents | Missing discharge summary, bills, or prescriptions | Fixable — resubmit with complete documents |
If the insurer rejected without giving a reason in writing, that itself is a violation. File a complaint immediately.
—
Every insurer must have a Grievance Redressal Officer. This is your first stop.
What to do:
Timeline: The insurer must respond within 15 days (IRDAI regulation on grievance redressal).
If the insurer does not respond in 15 days, or rejects again → go to Step 2.
—
IRDAI (Insurance Regulatory and Development Authority of India) runs a free online complaint system called IGMS (Integrated Grievance Management System).
How to file:
Timeline: IRDAI forwards your complaint to the insurer. The insurer must resolve it within 15 days of IRDAI forwarding.
Cost: Free.
IGMS reference number: You get a tracking number. Keep it safe.
If the insurer still does not resolve the complaint, IRDAI takes it up directly. See our full IRDAI complaint guide.
—
If the insurer rejects your complaint or does not respond, the Insurance Ombudsman is your next step. This is a free, government-appointed independent body.
What the Ombudsman can do:
Who can file:
How to file:
Cost: Free. No lawyer needed.
Timeline: The Ombudsman typically gives a decision within 3-6 months. The decision is binding on the insurer (up to ₹50 lakh). If you are not happy, you can still go to consumer court.
—
If the Ombudsman does not give relief (or your claim is above ₹50 lakh), you can file a consumer complaint.
Where to file:
You can file online through eDaakhil (edaacrhil.nic.in). See our complete consumer court filing guide.
Cost: ₹5,000-₹50,000 depending on the claim amount (court fee).
Timeline: 6-18 months typically. Faster than civil court.
Consumer court is powerful for insurance disputes because rejecting a valid claim = “deficiency in service” under the Consumer Protection Act 2019. See how courts have ruled against insurers.
—
If your insurer is a government-owned (public sector) company, it is a “public authority” under the RTI Act. This means you can file an RTI to get internal information about your claim.
Government-owned insurers (RTI applies):
Private insurers (RTI does NOT apply directly): HDFC Ergo, ICICI Lombard, Star Health, Niva Bupa, Bajaj Allianz, etc. But you CAN file RTI on IRDAI (the regulator) to get information about your complaint status + actions taken.
What RTI can get you:
How to file: See our simple RTI guide + first appeal guide. The RTI fee is ₹10. File online via RTI Online or at the insurer's head office.
RTI is powerful because insurers cannot hide behind “internal policy” once you have the documents.
Learn more in the free RTI Playbook.
—
| Stage | Maximum time allowed | Rule |
| — | — | — |
| Insurer asks for documents | Must list ALL required documents at once | IRDAI Claim Procedure Regulations |
| Claim decision (after all documents received) | 30 days | IRDAI regulations |
| Cashless authorization (hospital) | 3 hours for final response | IRDAI 2020 cashless guidelines |
| Rejection letter | Must state exact reason + clause in writing | IRDAI regulation |
| Internal grievance resolution | 15 days | IRDAI grievance redressal |
| IGMS complaint resolution | 15 days from IRDAI forwarding | IRDAI IGMS rules |
| Ombudsman filing deadline | 1 year from insurer's final rejection | Insurance Ombudsman Rules 2017 (amended 2021) |
If the insurer misses ANY of these timelines, that itself is grounds for complaint.
—
Ramesh bought a family floater policy. His mother was hospitalised for a heart surgery costing ₹3 lakh. The insurer rejected the cashless request saying “pre-existing disease not declared.”
What Ramesh did:
The key: Ramesh had his medical records in order. If your insurer claims “pre-existing disease,” demand they prove it with YOUR medical history.
—
No. IRDAI rules say the insurer MUST give a written rejection stating the exact reason and policy clause. If you got a verbal rejection or no reason, file a complaint immediately with IRDAI IGMS.
Pay from your pocket (keep all bills), then file a reimbursement claim. If the insurer rejects reimbursement too, follow the 4-step process above. Also see our cashless denial guide. The insurer MUST respond to a cashless request within 3 hours. If they did not respond in time, that is a violation.
Not directly — private companies are not “public authorities” under the RTI Act. But you CAN file RTI on IRDAI (the regulator) to get information about your complaint + what action IRDAI took. Government-owned insurers (LIC, New India Assurance, etc.) ARE under RTI. See our RTI guide.
Typically 3-6 months from filing. The Ombudsman's decision is binding on the insurer (up to ₹50 lakh). You do not need a lawyer. It is free. File at insuranceombudsman.org.
The Ombudsman can only award up to ₹50 lakh. For higher amounts, file a consumer complaint with the State or National Consumer Commission. See our consumer court guide.
The insurer must PROVE that you knew about the condition and deliberately hid it. If you were never diagnosed, the insurer cannot claim non-disclosure. Courts have ruled in favour of policyholders repeatedly on this. See the court rulings.
Yes. You must file with the Ombudsman within 1 year of the insurer's final rejection. For consumer court, the limitation is 2 years from the date of rejection (Consumer Protection Act 2019). File as early as possible.
—
—