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Health insurance claim rejected? What to do next in India
Last reviewed: 13 August 2026.
Quick answer: Ask the insurer for the written decision, the exact policy clause and the calculation sheet. Compare those with the policy schedule, wording, proposal form and medical records. Complain first to the insurer's grievance officer. If the insurer does not resolve it, register the grievance through IRDAI's Bima Bharosa system and consider the Insurance Ombudsman or Consumer Commission. Cashless denial does not automatically end a valid reimbursement claim.
Before you appeal: identify the decision
“Rejected” is often used for different events. A hospital may be outside the cashless network; the pre-authorisation request may lack records; or the insurer may have formally repudiated the claim. Ask for the exact written status.
| Document | What to check |
|---|---|
| Rejection or repudiation letter | Reason, policy clause, date and authorised signatory |
| Policy schedule and wording | Sum insured, room category, waiting periods, exclusions and co-payment |
| Proposal form | What medical history was asked and what was disclosed |
| Claim calculation | Each disallowed amount and the clause applied |
| Hospital file | Admission note, discharge summary, prescriptions, bills and diagnostic reports |
IRDAI's current health guidance states that waiting periods, including the pre-existing-disease waiting period, may be up to 36 months. It also describes a 60 continuous-month moratorium, after which a policy or claim is generally not contestable for non-disclosure or misrepresentation except established fraud; enhanced sum insured has its own continuity calculation. Apply the rule to the policy dates and facts, not as a blanket promise that every claim must be paid.
A practical appeal in four stages
- Write to the insurer's grievance officer. Quote the policy and claim numbers, reproduce the rejection reason, identify the clause you dispute and state the remedy: reconsideration, a speaking decision and the claim calculation. Attach an indexed PDF, not scattered photographs.
- Use Bima Bharosa when needed. IRDAI's Bima Bharosa portal records and tracks insurance grievances. It does not itself replace the insurer's claim assessment, so include the insurer complaint and response.
- Consider the Insurance Ombudsman. Check the current eligibility, territorial office, monetary jurisdiction and filing conditions on the official Council for Insurance Ombudsmen portal before filing. The service is designed for eligible policyholder disputes and does not require a paid agent.
- Use a Consumer Commission for adjudication. If evidence and the remedy sought make this appropriate, use the official e-Jagriti platform and verify jurisdiction and limitation. NCH is useful at the pre-litigation stage; it does not guarantee a remedy.
Do not run mutually inconsistent cases without understanding their maintainability. Preserve limitation by checking the current rules rather than waiting indefinitely for informal follow-up.
Cashless was denied but treatment is urgent
IRDAI's health FAQ currently lists one hour for a pre-authorisation decision and three hours for final authorisation after the hospital's discharge request. A failure to meet those service standards should be documented. However, treatment decisions belong to the patient and clinical team. Ask the insurer and hospital whether reimbursement remains available, collect originals or certified records, and do not describe cashless denial as final claim repudiation unless the insurer says so in writing.
For a focused checklist, see cashless approval delay and hospital records. For a dispute specifically about medical history, use the pre-existing-disease claim guide.
If the insurer says “non-disclosure”
Ask four questions: What fact was allegedly not disclosed? Which proposal-form question required it? What evidence shows the insured knew it? How did it affect underwriting or the claim? Compare the answer with the moratorium and waiting-period provisions applicable to the policy. Do not create a retrospective medical narrative; rely on contemporaneous records.
Can RTI help?
RTI can seek existing records from a public-sector insurer because it is a public authority. It cannot order payment or ask the PIO to decide whether repudiation was lawful. Request records narrowly: claim notes, the medical opinion relied on, the applicable circular, movement dates and the calculation sheet, subject to lawful exemptions. For private insurers, use the insurer, Bima Bharosa, Ombudsman and consumer-law routes instead.
Official sources
Is a cashless rejection the same as claim rejection?
No. Cashless is a payment arrangement. Ask whether you may submit a reimbursement claim and what records are required.
Must the insurer give a reason?
Demand a written decision identifying the policy clause and calculation. That is essential for any meaningful grievance or appeal.
Can I file RTI against a private insurer?
Ordinarily no. RTI applies to public authorities. Use the insurer's grievance channel, Bima Bharosa, Ombudsman or Consumer Commission as applicable.