Health Insurance Claim Rejected? What to Do Next in India (2026)

Reviewed on 2026-08-02 by Dr. Shrawan Kumar Pathak.

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.

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Before you fight, understand the reason. Insurers must give you a written rejection letter stating the exact clause and reason. Common reasons:

If the insurer rejected without giving a reason in writing, that itself is a violation. File a complaint immediately.

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Every insurer must have a Grievance Redressal Officer. This is your first stop.

What to do:

1. Write a complaint (email + registered post) to the insurer's grievance officer.
2. Include: policy number, claim number, date of rejection, why you think it is wrong, and what you want (full claim amount + reason in writing).
3. Attach: rejection letter, medical records, hospital bills, discharge summary.

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.

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IRDAI (Insurance Regulatory and Development Authority of India) runs a free online complaint system called IGMS (Integrated Grievance Management System).

How to file:

1. Go to consumerhub.irda.gov.in (the official IRDAI complaint portal).
2. Register with your email and mobile number.
3. Select your insurer, enter policy/claim details, and describe your complaint.
4. Upload the rejection letter + supporting documents.

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.

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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:

1. Award compensation up to ₹50 lakh (increased from ₹20 lakh in 2021).
2. Direct the insurer to pay your claim.
3. Award additional compensation for mental harassment.

Who can file:

1. Any policyholder whose claim was rejected, partially paid, or delayed.
2. You must have first filed with the insurer's grievance officer AND IGMS.

How to file:

1. Download the complaint form from insuranceombudsman.org (or check the nearest Ombudsman centre — there are 24 across India).
2. File within 1 year of the insurer's final rejection.
3. Attach: all correspondence, rejection letters, IGMS reference, medical records.

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.

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If the Ombudsman does not give relief (or your claim is above ₹50 lakh), you can file a consumer complaint.

Where to file:

1. Claims up to ₹50 lakh: District Consumer Disputes Redressal Commission.
2. ₹50 lakh to ₹2 crore: State Commission.
3. Above ₹2 crore: National Commission (NCDRC).

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.

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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):

1. LIC (Life Insurance Corporation)
2. New India Assurance
3. Oriental Insurance
4. National Insurance
5. United India Insurance
6. GIC Re

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:

1. The internal claim assessment report (why exactly was it rejected?).
2. The medical board's evaluation notes.
3. Internal correspondence on your claim.
4. Claim settlement ratio data for your specific policy.

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.

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If the insurer misses ANY of these timelines, that itself is grounds for complaint.

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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:

1. Step 1: Filed a written grievance with the insurer (the rejection mentioned PED, but Ramesh's mother had never been diagnosed with heart disease before — the insurer had no proof).
2. Step 2: No response in 15 days. Filed IGMS complaint online.
3. Step 3: Insurer still rejected. Ramesh filed with the Insurance Ombudsman with all medical records proving no prior diagnosis.
4. Result: The Ombudsman ordered the insurer to pay ₹3 lakh + ₹10,000 for delay harassment. Total time: 4 months.

The key: Ramesh had his medical records in order. If your insurer claims “pre-existing disease,” demand they prove it with YOUR medical history.

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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.

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1. Policy document (all pages, especially exclusions).
2. Rejection letter from the insurer (if verbal, demand it in writing).
3. All medical records: discharge summary, bills, test reports, prescriptions, doctor's notes.
4. Proof of premium payment.
5. All correspondence with the insurer (emails, letters, messages).
6. IGMS reference number (if you filed online).
7. Any evidence that the condition was NOT pre-existing (prior clean medical reports).

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• IRDAI Claim Procedure Regulations (regulation on 30-day settlement + document requirements): irda.gov.in
• IRDAI Grievance Redressal Rules (15-day internal resolution): irda.gov.in
• IGMS / Consumer Hub (online complaint portal): consumerhub.irda.gov.in
• Insurance Ombudsman Rules 2017 (amended 2021 — ₹50 lakh limit + 1-year filing): insuranceombudsman.org
• Consumer Protection Act 2019 (consumer court for deficiency of service): consumerhelpline.gov.in
• RTI Act 2005 (Section 6 — filing RTI against government-owned insurers): rtionline.gov.in
• Supreme Court rulings on insurance ambiguity + non-disclosure: See our detailed analysis + court rulings page