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practical-guides:employer-group-health-insurance-claim-rejected-after-leaving-job [2026/06/05 04:00] – created - external edit 127.0.0.1practical-guides:employer-group-health-insurance-claim-rejected-after-leaving-job [2026/06/13 07:57] (current) – Batch 1 rewrite: answer-first, topic-specific content and metadata Shrawan Pathak
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-{{htmlmetatags>metatag-title=(Group Health Claim Rejected After Leaving Job? Appeal Guide)&metatag-description=(Group health insurance claim rejected because you had left the job? Learn how cover-ceases-on-exit works and how to appeal via insurer, IRDAI and ombudsman.)&metatag-keywords=(group health insurance, claim rejection, cover ceases on exit, IRDAI Bima Bharosa, insurance ombudsman, portability)&metatag-robots=(index,follow)&metatag-og:title=(Group Health Claim Rejected After Leaving Job? Appeal Guide)&metatag-og:description=(Group health insurance claim rejected because you had left the job? Learn how cover-ceases-on-exit works and how to appeal via insurer, IRDAI and ombudsman.)&metatag-og:type=(article)}}+{{htmlmetatags>metatag-title=(Group Health Claim Rejected After You Left the Job? Appeal Route)&metatag-description=(Group health claim rejected because you had left the job? It turns on one date. Learn the appeal route and how IRDAI portability protects future cover.)&metatag-keywords=(Insurance Claims)&metatag-robots=(index,follow)&metatag-og:title=(Group Health Claim Rejected After You Left the Job? Appeal Route)&metatag-og:description=(Group health claim rejected because you had left the job? It turns on one date. Learn the appeal route and how IRDAI portability protects future cover.)&metatag-og:type=(article)}}
  
-====== Group Health Claim Rejected After Leaving Job? Appeal Guide ======+====== Group Health Insurance Claim Rejected After Leaving the Job ======
  
-**You used your employer's group health insurance, but the claim was rejected because you had already left the job. This is one of the most common and most upsetting insurance surprises in India. The good news: it often turns on a single date, and there is a clear appeal path. This guide explains how cover ends on exit, what evidence to gather this weekend, and how to escalate to the insurer, IRDAI and the Insurance Ombudsman.**+**Reviewed on:** 2026-06-12.
  
 {{:practical-guides:employer-group-health-insurance-claim-rejected-after-leaving-job.webp|Group Health Claim Rejected After Leaving Job? Appeal Guide}} {{:practical-guides:employer-group-health-insurance-claim-rejected-after-leaving-job.webp|Group Health Claim Rejected After Leaving Job? Appeal Guide}}
  
-**Reviewed on:** 2026-05-29.+**Direct answer:** Group cover usually ends when your employment ends, often on your last working day or when HR removes your name from the master policy. Whether your claim is valid turns on one comparison, the date of admission against the date your cover ceased, not your salary. First, get the exact cover-cease date and the deletion date from HR and the third-party administrator (TPA) in writing. If the admission fell within the cover, send a written appeal to the insurer's grievance officer, then escalate on IRDAI's Bima Bharosa portal, and finally to the Insurance Ombudsman. If the admission fell after cover ended, the original claim may not revive, but IRDAI portability lets you carry your continuity benefits into an individual policy. Save every email; the date trail is your case.
  
-<WRAP center round info 95%> +This guide is for salaried employees and their dependants in India whose hospitalisation claim was rejected on the ground that the employee had already resigned, retired, or been separated.
-**Quick answer**+
  
-Group health cover usually ends when your employment ends, often on your last working day or when HR removes your name from the master policy. Whether your claim is valid turns on the date of admission compared to the date cover ceased for you, not your salary. First, get the exact cover-cease date and the deletion date from HR and the TPA in writing. If the admission was within the cover, send a written appeal to the insurer's grievance officer, then escalate on the IRDAI Bima Bharosa portal, and finally to the Insurance Ombudsman. Save every email; the date trail is your case. +===== The two dates that decide everything =====
-</WRAP>+
  
-===== Who this guide is for =====+Almost every group-cover-after-exit dispute turns on this single comparison:
  
-This guide is for salaried employees and their dependants in India who were covered under an employer's group health insurance policy and have had a hospitalisation claim rejected on the ground that the employee had already resigned, retired or been separated. It is useful if you are:+  * **Date of admission** (or date of service) on the hospital record. 
 +  * **Date your cover ceased**, shown by your relieving letter and the deletion endorsement.
  
-  * An ex-employee whose claim was denied because the treatment date fell after your last working day. +If the admission falls within your cover period, the claim should be payable and the rejection is likely wrong. If it falls outside, your route is portability or a personal policy, not an appeal on the original claim. Salary credit rarely decides this; the policy roster does.
-  * An employee in your notice period who was hospitalised and is unsure whether you were still covered. +
-  * A dependant (spouse, child or parent) whose claim was tied to the primary member's exit date. +
-  * Someone who was told by the third-party administrator (TPA) that "the policy does not show you as a member" on the date of admission. +
-  * An employee planning to leave who wants to protect continuity through portability or a personal policy before the cover lapses.+
  
-The core issue is timing: **group cover usually ceases on exit**, and the dispute is almost always about the date of admission versus the date your cover ended. This is different from claim rejections about pre-existing diseases, room-rent limits or cashless delays. If your problem is one of those instead, see the related guides linked at the end. To compare your continuity options before or just after leaving, read our companion guide on [[/practical-guides/corporate-health-insurance-continuity-after-job-change/|corporate health insurance continuity after a job change]].+===== Why cover ceases on exit =====
  
-===== What you can do this weekend =====+A group health policy is a contract between your employer and the insurer. You are a member, not the policyholder. When you leave, the employer normally removes your name and your cover ends. The exact trigger varies by policy. It may be your last working day, the end of the policy month, or the date HR sends the deletion request to the insurer. There is no single national rule, so you must read the actual clause. Ask HR in writing which date applies, and for a copy of the cessation clause.
  
-==== Friday evening ====+===== What to do this weekend =====
  
-Find your rejection communication first. It may be an SMS, an email from the TPA, or a letter. Read the exact reason. In these cases the reason is usually phrased as "member not active on date of admission" or "cover ceased on exit". Note the date the insurer says your cover ended.+  - **Find the rejection in writing.** SMS, email, or letter. Read the exact reason, usually "member not active on date of admission" or "cover ceased on exit". Note the date the insurer says cover ended. 
 +  - **Pull two dates.** Date of admission from the hospital record, and last working day from your relieving letter. Write both down. 
 +  - **Email HR.** Ask for your relieving letter, last working day, the exact date your name was deleted from the policy, and the cessation clause. 
 +  - **Email the TPA or insurer.** Ask for the master policy number, your member endorsement with inclusion and deletion dates, and a written rejection stating the reason and clause. A verbal "no" is not enough. 
 +  - **Build a one-page timeline** of all key dates and keep every document in one folder.
  
-Now pull out two dates that decide everything. The first is the **date of admission** (or date of service) on your hospital records. The second is your **last working day** as shown on your relieving or experience letter. Write both down clearly. If the admission was on or before your last working day, you have a strong position.+===== Documents and evidence =====
  
-Open a single folder, physical or digital, and start dropping every document into it. Treat this folder as your case file from the very first evening.+^ Document ^ What it proves ^ 
 +| Written claim rejection (letter, email, SMS) | The exact reason and date relied on | 
 +| Relieving / experience letter | Your official last working day | 
 +| Member endorsement from the group policy | Your inclusion and deletion dates | 
 +| Cessation-of-cover clause | When cover ends on exit under the master policy | 
 +| Hospital admission and discharge records | Exact admission, treatment and discharge dates | 
 +| Final bill and payment receipts | The amount claimed | 
 +| Cashless pre-authorisation or denial slip | The date the TPA checked membership |
  
-==== Saturday ====+===== Escalation ladder =====
  
-Email your former HR. Keep it factual. Ask, in writing, for four things: your relieving letter, your last working day, the exact date your name was deleted from the group health policy, and the specific policy clause that governs when cover ceases on exit. Request a reply by email so you have a record.+^ Stage ^ Action ^ Where ^ 
 +| 1 | Get the cover-cease date, deletion date and clause in writing | Former employer HR; TPA / insurer | 
 +| 2 | Written appeal with timeline and evidence | Insurer's grievance redressal officer | 
 +| 3 | Regulator complaint with policy and rejection details | IRDAI Bima Bharosa grievance portal | 
 +| 4 | Free personal-line dispute resolution | Insurance Ombudsman for your area | 
 +| 5 | RTI for group-policy records (only if employer is govt/PSU) | CPIO of the department or PSU |
  
-Separately, email the TPA or insurer. Ask for the master policy number, the member endorsement showing your inclusion and deletion dates, and a written claim rejection letter that states the reason and the policy clause relied on. A verbal "no" on a call is not enough; insist on it in writing.+===== If cover really ended: portability protects your future =====
  
-While you wait for replies, organise your hospital paperwork. Make sure the admission date, discharge date and the final bill are all legible. If the hospital issued a cashless denial during admission, find that document too, because it often records the date the TPA checked your membership.+If the admission genuinely fell after your cover ceased, the original claim may not be revivable, but your continuity still matters. IRDAI rules allow a member to port or migrate from a group policy to an individual or retail policy, subject to conditions and timelines, usually within a window around exit. Acting quickly protects waiting periods you have already served. Ask the insurer and TPA in writing about portability, any grace period, and the deadline. For the full comparison, read our companion guide on [[practical-guides:corporate-health-insurance-continuity-after-job-change|corporate health insurance continuity after a job change]].
  
-==== Sunday ==== +===== Appeal letter to the insurer =====
- +
-Draft your appeal to the insurer using the template in this guide as a starting point. Lead with the dates. Your argument is simple: the treatment fell within the period you were covered, and the policy clause supports you. Attach your evidence in a numbered annexure list. +
- +
-Build a one-page timeline: date you joined, date of resignation or separation, last working day, date of admission, date of discharge, date cover allegedly ceased, and date of rejection. A clean timeline makes your case obvious to any officer who reads it later. +
- +
-If the amount is large or the medical situation is serious, note down a question or two for a qualified insurance advisor or lawyer. You do not have to engage one yet, but knowing what you would ask saves time on Monday. +
- +
-===== Documents and evidence checklist ===== +
- +
-^ Document ^ What it proves ^ Where to get it ^ +
-| Claim rejection letter / email / SMS | The exact reason and date the insurer relied on | TPA or insurer; your email and message inbox | +
-| Relieving / experience letter | Your official last working day | Former employer's HR | +
-| Resignation acceptance / separation letter | Date your separation was formally recorded | HR / your email records | +
-| Member endorsement from the group policy | Your inclusion date and deletion date on the policy | HR, TPA or insurer (request in writing) | +
-| Group policy clause on cessation of cover | When cover ends on exit under the master policy | HR or insurer (ask for the specific clause) | +
-| Hospital admission and discharge records | Exact date of admission, treatment and discharge | Hospital records / billing department | +
-| Final hospital bill and payment receipts | Amount claimed and that you paid it | Hospital billing department | +
-| Cashless pre-authorisation / denial slip | Date the TPA checked membership during admission | Hospital insurance desk / TPA | +
-| Health card / e-card under the group policy | You were an enrolled member with a policy number | TPA app, HR portal or your records | +
-| Email trail with HR and TPA | You sought clarity and exercised due diligence | Your email account (export with timestamps) | +
-| One-page event timeline (prepared by you) | All key dates in one view for any officer | Prepare yourself from the documents above | +
- +
-===== Step-by-step action plan ===== +
- +
-==== Step 1 — Pin down the two dates that decide the claim ==== +
- +
-Almost every group-cover-after-exit dispute turns on one comparison: the **date of admission** versus the **date your cover ceased**. Read your hospital admission record for the first date. Read your relieving letter and the insurer's rejection for the second. If the admission falls within your cover period, your claim should be payable and the rejection is likely wrong. If it falls outside, your route is portability or a personal policy, not an appeal on the original claim. +
- +
-==== Step 2 — Understand the cover-ceases-on-exit concept ==== +
- +
-A group health policy is a contract between your employer and the insurer. You are a member, not the policyholder. When you leave, the employer normally removes your name and your cover ends. The exact trigger varies by policy: it may be your last working day, the end of the policy month, or the date HR sends the deletion request to the insurer. There is no single national rule, so you must read the actual clause. This is also why the gap between your salary stopping and your cover ending can differ. Ask HR which date applies and get the clause in writing. +
- +
-==== Step 3 — Build the HR and TPA email trail ==== +
- +
-Put your questions to HR and to the TPA or insurer in writing, by email, on the same day. From HR, request your relieving letter, last working day, the exact date of deletion from the policy, and the cessation clause. From the TPA or insurer, request the policy number, your member endorsement with inclusion and deletion dates, and the written rejection with reasons. Written replies create the evidence you will rely on right up to the ombudsman. Avoid settling for phone calls that leave no record. +
- +
-==== Step 4 — Send a written appeal to the insurer's grievance officer ==== +
- +
-Every insurer has a grievance redressal officer and a published grievance process. Send a clear, dated representation that leads with your timeline and asks the insurer to reconsider and pay the claim. Attach the rejection letter, your relieving letter, the member endorsement, the hospital records and your one-page timeline. Ask for a written decision and keep the acknowledgement. Do not let a verbal rejection stand without putting your appeal on record. +
- +
-==== Step 5 — Check your grace period and portability options ==== +
- +
-If the admission genuinely fell after your cover ended, the original claim may not be revivable, but your future protection still matters. IRDAI rules allow members to port or migrate from a group policy to an individual policy, subject to conditions and timelines, usually within a window around exit. Ask the insurer and TPA in writing about portability, any grace period and the deadline. Acting quickly here protects your continuity benefits and any waiting periods you have already served. Our guide on [[/practical-guides/corporate-health-insurance-continuity-after-job-change/|corporate health insurance continuity after a job change]] walks through these options. +
- +
-==== Step 6 — Escalate to IRDAI through the Bima Bharosa portal ==== +
- +
-If the insurer rejects your appeal or does not respond within the timeline stated in its grievance policy, register a complaint with the regulator. The Insurance Regulatory and Development Authority of India (IRDAI) runs a grievance system known as **Bima Bharosa**. Lodge your complaint there with the policy number, the rejection details and your documents. This creates a regulator-level record and often prompts the insurer to re-examine the file. For a walkthrough, see our guide on filing an [[/file-insurance-complaint-irdai-2026|insurance complaint with IRDAI]] and the dedicated [[/bima-bharosa-health-insurance-complaint-guide|Bima Bharosa health insurance complaint guide]]. +
- +
-==== Step 7 — Approach the Insurance Ombudsman ==== +
- +
-If the regulator route does not resolve it, the **Insurance Ombudsman** handles personal-line disputes, including health claims, free of cost. There are ombudsman offices across India, each covering a defined territory. You normally approach the ombudsman after the insurer's final reply, or after the grievance went unanswered for the prescribed time, and the matter should not already be in court. Submit your complaint with the rejection letter, your representation, the insurer's reply and your evidence. Confirm the current timelines and monetary limits on the official portal before filing. +
- +
-==== Step 8 — Consider professional help for larger or disputed claims ==== +
- +
-If the amount is large, the medical issue is serious, or the dates are genuinely contested, consider a qualified insurance advisor or a consumer-law professional. They can assess whether a consumer commission complaint is worthwhile after the ombudsman stage. Keep this in proportion: for many cases, a well-documented appeal, IRDAI Bima Bharosa and the ombudsman are enough to resolve the matter without litigation. +
- +
-===== Escalation ladder ===== +
- +
-^ Stage ^ Action ^ Forum / Destination ^ Target timeline ^ +
-| 1 | Get cover-cease date, deletion date and policy clause in writing | Former employer HR; TPA / insurer | Request immediately; chase within a few days | +
-| 2 | Written appeal with timeline and evidence | Insurer's grievance redressal officer | As per insurer's published grievance timeline | +
-| 3 | Regulator complaint with policy and rejection details | IRDAI Bima Bharosa grievance portal | File after insurer's reply or non-response | +
-| 4 | Free personal-line dispute resolution | Insurance Ombudsman for your territory | Within the period set by ombudsman rules | +
-| 5 | RTI for group policy records (only if employer is govt/PSU) | CPIO of the government department or PSU employer | 30 days (RTI Act, Section 7) | +
-| 6 | Consumer complaint, if warranted after ombudsman | Appropriate consumer commission (with professional advice) | As per consumer-protection timelines | +
- +
-===== Copy-paste complaint template ===== +
- +
-Replace the text in square brackets with your own details before sending.+
  
 +<code>
 To, To,
 The Grievance Redressal Officer The Grievance Redressal Officer
-[Name of Insurance Company] +[Name of Insurance Company], [Address]
-[Address of Grievance Cell] +
- +
-Date: [DD/MM/YYYY]+
  
-Subject: Appeal against rejection of group health insurance claim — +Subject: Appeal against rejection of group health claim - 
-         Policy No. [Group Policy Number], Claim No. [Claim Number]+Policy No. [Group Policy No.], Claim No. [Claim No.]
  
 Respected Sir / Madam, Respected Sir / Madam,
  
-1. I am [Your Name], a member (or dependant of member) under the group +1. I am [Your Name], a member / dependant under the group health policy taken 
-   health insurance policy taken by my former employer +   by my former employer [Employer Name], Policy No. [Group Policy No.]. 
-   [Employer Name], Policy No. [Group Policy Number]. +2. I was hospitalised at [Hospital] with admission [DD/MM/YYYY] and discharge 
- +   [DD/MM/YYYY] for [brief description]. The claim amount is Rs [amount]. 
-2. I was hospitalised at [Hospital Name] with date of admission +3. The claim was rejected vide [letter / email / SMS] dated [DD/MM/YYYY] on the 
-   [DD/MM/YYYY] and date of discharge [DD/MM/YYYY] for treatment of +   ground that cover had ceased on exit. 
-   [brief description]. The claim amount is Rs [Amount]. +4. Key dates: joining [DD/MM/YYYY]; last working day [DD/MM/YYYY]; deletion from 
- +   policy [DD/MM/YYYY]; admission [DD/MM/YYYY]. 
-3. My claim has been rejected vide [letter / email / SMS] dated +5. As the admission falls within the period I was a covered member, the claim is 
-   [DD/MM/YYYY] on the ground that my cover had ceased on exit from +   payable. I rely on the cessation clause, enclosed. 
-   employment. +6. I request you to reconsider and settle Rs [amount], or to issue a written 
- +   speaking order stating the exact clause and the exact date cover ceased.
-4. I respectfully submit the following key dates: +
-   (a) Date of joining employment: [DD/MM/YYYY] +
-   (b) Last working day (per relieving letter): [DD/MM/YYYY] +
-   (c) Date of deletion from group policy (per HR / endorsement): +
-       [DD/MM/YYYY] +
-   (d) Date of admission: [DD/MM/YYYY] +
- +
-5. As the date of admission falls [within / before] the period for which +
-   I was a covered member under the master policy, the claim is payable +
-   under the policy terms. I rely on the policy clause governing +
-   cessation of cover, a copy of which is enclosed. +
- +
-6. I therefore request you to reconsider and settle the claim of +
-   Rs [Amount], or to provide a written speaking order stating the exact +
-   clause and the exact date on which my cover is said to have ceased. +
- +
-7. I am available for any clarification and can submit original documents +
-   on request.+
  
 Yours faithfully, Yours faithfully,
 +[Your Full Name], [Member ID], [mobile, email]
  
-[Your Full Name] +Enclosures: rejection letter, relieving letter, member endorsement, hospital 
-[Member ID / Health Card Number] +records, final bill, one-page timeline, email trail with HR and TPA. 
-[Mobile Number] +</code>
-[Email Address] +
- +
-Enclosures: +
-A — Claim rejection communication dated [DD/MM/YYYY] +
-B — Relieving / experience letter +
-C — Member endorsement showing inclusion and deletion dates +
-D — Hospital admission and discharge records +
-E — Final hospital bill and payment receipts +
-F — One-page timeline of key dates +
-G — Email trail with HR and TPA+
  
 ===== When RTI can help ===== ===== When RTI can help =====
  
-The Right to Information Act, 2005 applies to public authorities. In a group-health-after-exit dispute, RTI is useful only in a narrow situation: **when your former employer is a government department or a public-sector undertaking (PSU)** that holds the group policy. In that case the employer is a public authority and you can seek records about the policy and your membership. You could file an RTI with the Central Public Information Officer (CPIO) of the department or PSU and ask for items such as: +The RTI Act, 2005 applies to public authorities. Here it helps only when your former employer is a **government department or a PSU** that holds the group policy. Then you can ask the Central Public Information Officer for a copy of the master policy and the cessation clause, the exact dates your name was added and deleted, and any internal correspondence with the insurer or TPA about your membership around the hospitalisation. These records settle the date dispute. See [[file-rti-online-india|how to file an RTI online]] and [[act:section-19|first and second appeals]].
- +
-  * A copy of the group health insurance master policy and the clause on cessation of cover on exit. +
-  * The exact date your name was added to and deleted from the group policy roster, and the date the deletion request was sent to the insurer. +
-  * Any internal correspondence between the employer and the insurer or TPA about your membership status around the date of your hospitalisation. +
- +
-These records can settle the date dispute that is at the heart of your claim. To file an RTI, see our step-by-step guide on [[/file-rti-online-india|filing an RTI online]]. If the CPIO does not respond within the prescribed time, our guide on [[/file-first-appeal-rti-section-19-2026|filing a first appeal under RTI Section 19]] explains the next step. For combining RTI with grievance routes, see [[/cpgrams-rti|how to use CPGRAMS and RTI together]], and for deeper strategy read [[/book|The RTI Playbook]].+
  
 ===== When RTI will not help ===== ===== When RTI will not help =====
  
-For most readers, RTI will not reach the body that actually decided your claim:+  * **Private insurers and private TPAs are not public authorities.** RTI does not reach their internal claim notes. 
 +  * **RTI cannot pay or reverse a claim.** It only gives information. The substantive remedy is the insurer grievance route, then IRDAI Bima Bharosa, then the Ombudsman. 
 +  * **It is slower than the dedicated channels.** Use it to support your case, not as your main remedy.
  
-  * **Private insurers and private TPAs are not public authorities:** If your employer is a private company and the insurer is a private company, RTI does not apply to either. You cannot use RTI to get their internal claim notes or to force a decision. +===== Common mistakes =====
-  * **RTI cannot pay or reverse a claim:** RTI is only a tool to access information. It does not direct an insurer to settle. The substantive remedy is the insurer grievance route, then IRDAI Bima Bharosa, then the Insurance Ombudsman. +
-  * **It is slower than the dedicated channels:** Even where RTI applies, the 30-day response window is usually slower than escalating directly to the regulator and the ombudsman. Use RTI to support your case, not as your main remedy.+
  
-===== Common mistakes to avoid ===== +  * Arguing about salary instead of the two dates. 
- +  * Accepting a verbal rejection without a written reason and clause. 
-  * **Arguing about salary instead of dates:** Whether your salary was still being credited rarely decides the claim. What matters is the date of admission versus the date cover ceased. Lead with those two dates. +  * Not getting the deletion date from HR. 
-  * **Accepting a verbal rejection:** A phone call denying the claim is not a record. Always insist on a written rejection that states the exact reason and clause, so you can appeal on solid ground. +  * Missing the portability window while arguing about the old claim. 
-  * **Not getting the deletion date from HR:** Many disputes are resolved the moment HR confirms in writing that you were deleted after your admission date. Ask for it early and in writing. +  * Skipping the insurer grievance stage; the Ombudsman expects it first. 
-  * **Missing the portability window:** If your cover really did end, you may still protect continuity by porting to an individual policy, but only within a limited window. Do not let that deadline pass while you argue about the old claim. +  * Putting guessed timelines or section numbers in your complaint.
-  * **Skipping the insurer grievance stage:** The ombudsman usually expects you to have approached the insurer first. Sending a written appeal to the grievance officer is not optional; it is the gateway to escalation. +
-  * **Quoting fees, sections or limits you are not sure of:** Do not put guessed timelines, fee amounts or section numbers in your complaint. State your facts and dates, and let the official confirm the limits. Verify current timelines on the official portals before filing. +
-  * **Letting the rejection letter sit:** Escalation timelines run from the insurer's reply. Acting promptly keeps every door open, including the ombudsman. +
-  * **Treating a PED, room-rent or cashless rejection as the same issue:** Those are governed by different clauses and a different appeal angle. If that is your real problem, use the matching guide below instead of this one. +
- +
-If your rejection is actually about a pre-existing disease, see our guide on the [[/practical-guides/health-insurance-pre-existing-disease-claim-rejection-appeal/|pre-existing disease claim rejection appeal]]. If it is about a cashless approval being stuck, see the [[/practical-guides/health-insurance-cashless-approval-delay-tpa-hospital/|cashless approval delay guide]]. +
- +
-===== Official links ===== +
- +
-  * [[https://irdai.gov.in/|IRDAI (irdai.gov.in)]] — Insurance regulator; policyholder protection, rules and grievance information +
-  * [[https://bimabharosa.irdai.gov.in/|Bima Bharosa (bimabharosa.irdai.gov.in)]] — IRDAI's online grievance registration system for policyholders +
-  * [[https://www.cioins.co.in/|Council for Insurance Ombudsmen (cioins.co.in)]] — Insurance Ombudsman offices, territories and complaint process +
-  * [[https://pgportal.gov.in/|CPGRAMS (pgportal.gov.in)]] — Public grievance portal, relevant if your employer is a government department or PSU+
  
 ===== Frequently asked questions ===== ===== Frequently asked questions =====
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 ==== Why was my claim rejected if I was treated while still employed? ==== ==== Why was my claim rejected if I was treated while still employed? ====
  
-Group cover usually ceases on your last working day or the date your name is removed from the policy roster. What matters is the date of admission or date of service compared to the date cover ceased for you, not your salary credit. If the admission date falls after the cover-cease date, the insurer treats you as uncovered. Check your relieving letter, the date HR informed the insurer or TPA, and the exact admission date on the hospital records.+Group cover usually ceases on your last working day or the date your name is removed from the policy roster. What matters is the admission date against the cover-cease date, not your salary credit. If the admission falls after the cover-cease date, the insurer treats you as uncovered. Check your relieving letter, the date HR informed the insurer, and the exact admission date.
  
-==== Does my group cover end on my last working day or my resignation date? ====+==== Does my cover end on my last working day or my resignation date? ====
  
-It depends entirely on the master policy your employer holds and the terms agreed with the insurer. For some policies cover ends on the last working day; for others it runs to the end of the policy month or until HR deletes your name. There is no single national rule. Ask HR in writing for the exact date your name was deleted from the group policy and the clause that governs cessation of cover on exit.+It depends on the master policy and the terms agreed with the insurer. For some policies cover ends on the last working day; for others it runs to the end of the policy month or until HR deletes your name. There is no single national rule. Ask HR in writing for the exact deletion date and the cessation clause.
  
-==== Can I keep my group health cover after leaving the job? ====+==== Can I keep my group cover after leaving? ====
  
-Not automatically. Group cover belongs to the employer, not to you. However, IRDAI rules allow portability or migration from a group policy to an individual or retail policy with the same or another insurer, subject to conditions and timelines. You usually have to apply within a defined window around your exit. Ask the insurer and TPA in writing about portability options and the deadline, and do this before you leave if you can. +Not automatically; it belongs to the employer. But IRDAI rules allow portability or migration from a group policy to an individual policy, subject to conditions and timelines, usually within a defined window around exit. Ask the insurer and TPA in writing about portability and the deadline, ideally before you leave.
- +
-==== What should I ask HR and the TPA for in writing? ==== +
- +
-Ask HR for your relieving letter, your last working day, the exact date your name was deleted from the group policy, and a copy of the relevant policy clause on cover cessation. Ask the TPA or insurer for the policy number, the member endorsement showing your inclusion and deletion dates, and the written claim rejection with reasons. Keep every email; a clear paper trail is your strongest evidence at the ombudsman.+
  
 ==== How do I escalate after the insurer rejects my appeal? ==== ==== How do I escalate after the insurer rejects my appeal? ====
  
-First send a written representation to the insurer's grievance redressal officer and get an acknowledgement. If the reply is unsatisfactory or none comes within the timeline, register a complaint on IRDAI's Bima Bharosa portal. If that does not resolve it, approach the Insurance Ombudsman covering your area, which handles personal-line disputes free of cost. Keep your rejection letter, policy documents and the email trail ready for each stage.+Send a written representation to the insurer's grievance officer and keep the acknowledgement. If the reply is unsatisfactory or none comes in time, register a complaint on IRDAI's Bima Bharosa portal. If that does not resolve it, approach the Insurance Ombudsman for your area, which handles personal-line disputes free of cost.
  
 ==== Can I file an RTI against my insurer or TPA? ==== ==== Can I file an RTI against my insurer or TPA? ====
  
-Generally no. The RTI Act, 2005 applies to public authorities, not to private insurers or private TPAs. RTI can help only in the limited situation where your former employer is a government department or a public-sector undertaking, where you can seek the group policy records and the dates of your inclusion and deletion. For the insurance dispute itself, use the insurer grievance route, IRDAI Bima Bharosa and the Insurance Ombudsman.+Generally no. The RTI Act applies to public authorities, not private insurers or TPAs. RTI helps only in the narrow case where your former employer is a government department or PSU, where you can seek the group-policy records and your inclusion and deletion dates. For the dispute itself, use the insurer grievance route, Bima Bharosa, and the Ombudsman.
  
 ==== Is there a deadline to approach the Insurance Ombudsman? ==== ==== Is there a deadline to approach the Insurance Ombudsman? ====
  
-Yes. You normally have to approach the ombudsman within a defined period after the insurer's final reply or after the grievance went unanswered for the prescribed time, and the matter should not already be before a court or other forum. The exact timelines and monetary limits are set by the ombudsman rules. Confirm the current limits on the official ombudsman or IRDAI portals before filing, and do not let the rejection letter sit unaddressed.+Yes. You normally approach the Ombudsman within a defined period after the insurer's final reply or after the grievance went unanswered for the prescribed time, and the matter should not already be in court. The exact timelines and monetary limits are set by the ombudsman rules. Confirm current limits on the official portal before filing. 
 + 
 +===== Related guides ===== 
 + 
 +  * [[practical-guides:corporate-health-insurance-continuity-after-job-change|Corporate health insurance continuity after a job change]] 
 +  * [[practical-guides:employer-not-updating-date-of-exit-epfo|Date of exit not updated in EPFO]] 
 +  * [[practical-guides:employee-bond-training-cost-recovery-demand|Training bond recovery demand on exit]] 
 +  * [[practical-guides:start|Practical Guides hub]] 
 + 
 +Official links: [[https://irdai.gov.in|IRDAI]], [[https://bimabharosa.irdai.gov.in|Bima Bharosa grievance portal]], [[https://www.cioins.co.in|Council for Insurance Ombudsmen]]. 
 + 
 +Download the group-health-after-exit appeal checklist (PDF).