THE SARAL GUIDE

Health Insurance Claim Rejected? Why It Happens and What to Do, Step by Step

Updated Nov 2, 2026 Saral Jankari Team

A plain-language guide to a rejected health insurance claim in India: the common reasons, your rights under IRDAI rules, and the steps to follow, from writing to your insurer to the Bima Bharosa portal, the Insurance Ombudsman and the consumer commission.

A rejected health insurance claim feels like the end of the road, but it often is not. Many rejections come from missing paperwork or a misunderstanding, and you have several ways to challenge one. This guide explains the common reasons, what the rules say, and exactly what to do next, in order.

The short version

Get the rejection in writing and find the exact reason.
Check that reason against your policy document and your papers.
If it is a paperwork problem, fix it and send the claim again.
If you disagree, write to your insurer’s grievance team and keep a copy.
If you get no answer or a poor one, complain on IRDAI’s Bima Bharosa portal.
Then go to the Insurance Ombudsman (free, no lawyer needed), or to the consumer commission.

First: is it a rejection, or only a cashless refusal?

These are two different things. If the hospital says your cashless request was declined, the insurer has not rejected your claim. It has only refused to pay the hospital directly. You can usually pay the bill yourself and file a reimbursement claim afterwards with the bills and reports. Do not skip treatment because cashless was refused, and do not assume the claim is lost.

IRDAI’s 2024 circular says insurers must decide on a cashless request within one hour and give the final authorisation at discharge within three hours. If a refusal comes with no reason, ask for it in writing.

Common reasons for rejection, and what you can do

Waiting period not over. Pre-existing conditions and some named illnesses are covered only after a waiting period. Check the date your policy started and the waiting period in the policy. If the treatment was after it ended, the rejection may be wrong.
Pre-existing condition not disclosed. If the proposal form left out a known condition, the insurer may reject for non-disclosure. Look at what you actually wrote, and at medical records showing when the condition was first diagnosed.
Treatment is excluded. Cosmetic procedures and some other treatments are excluded by every policy. Ask the insurer to quote the exact clause. If the treatment was medically necessary, say so with a doctor’s letter.
Papers missing or unclear. Discharge summary, bills, prescriptions or test reports are not attached or do not match. This is the easiest problem to fix: send the missing documents and ask the insurer to reconsider.
Policy had lapsed. If the premium was not paid in time, cover may have stopped. The 2024 circular gives a grace period of 30 days for yearly, half-yearly or quarterly premiums and 15 days for monthly premiums. Check your payment dates.
Partial payment, not rejection. Room-rent limits, co-pay and sub-limits can reduce what you receive. This is a deduction, not a rejection, but you can still ask the insurer to explain the exact calculation.

Your rights under IRDAI rules

Time to settle. A health insurer must settle a claim within 30 days of receiving the last necessary document, and within 45 days if it needs to investigate. If it is late, it owes you interest at 2% above the bank rate.
Rejections are reviewed. IRDAI’s 2024 circular says a claims review committee must approve every rejection.
Long-running policies are protected. After 60 months of continuous cover (the moratorium), a claim cannot be contested for non-disclosure, except for proven fraud.
Waiting periods have a ceiling. For pre-existing diseases the maximum waiting period is 36 months. Our health insurance guide explains these terms.

What to do, step by step

Step 1: Get the reason in writing

Ask the insurer or TPA (the company that handles claims for the insurer) for a written rejection letter that states the reason and the policy clause used. Do not rely on a phone call. Note your claim number, policy number and the date.

Step 2: Compare it with your policy and papers

Read the clause they quote. Check your policy start date, waiting periods, the list of exclusions and your proposal form. Gather the hospital bills, discharge summary, doctor’s notes and test reports.

Step 3: Fix it or reply to it

If documents were missing, send them and ask for the claim to be reopened. If you think the reason is wrong, write a short, calm reply that explains why, with copies of the proof. Keep a copy of everything you send.

Step 4: Complain to the insurer’s grievance team

Every insurer has a grievance officer and a grievance email or form on its website. Send a written complaint, mention the claim number and what you want (for example, “please reconsider and pay my claim of ₹X”), and keep the acknowledgement. This step matters, because the next forums expect you to have tried it.

Step 5: Use the Bima Bharosa portal

If the insurer does not reply in about 15 days, or its answer does not help, register a complaint on IRDAI’s Bima Bharosa portal (bimabharosa.irdai.gov.in). You enter the policy details and the insurer’s name, upload your papers and get a complaint number to track. You can also call the toll-free number 155255 or email complaints@irdai.gov.in. IRDAI sends the complaint to the insurer and tracks it.

Step 6: Take it to the Insurance Ombudsman

The Insurance Ombudsman is an official who settles disputes between policyholders and insurers. You do not need a lawyer and there is no filing charge.

Before you go: you must first have complained to the insurer. You can approach the Ombudsman once the insurer has replied and you are unhappy, or one month after your written complaint if it did not reply.
Deadline: within one year of the insurer’s rejection or reply (or of the one-month wait ending). Late complaints may be accepted in some cases, so do not give up if you are late, but do not delay.
Limit: the amount you claim must be up to ₹30 lakh.
How: you can file online or on paper, with your complaint, the policy copy and your letters with the insurer.
Result: the Ombudsman first tries to get both sides to agree. If that fails, it issues an award, which is binding on the insurer but not on you. The insurer must comply within 30 days or pay ₹5,000 a day to you.

Step 7: Consumer commission or court

You can also file a complaint with the District Consumer Commission, which handles claims up to ₹50 lakh, usually within two years of the problem. You can file online through the e-Daakhil portal. Note that the Ombudsman will not take a matter that is already before a consumer forum or court, so choose one route at a time.

An example

Suppose a claim for a heart procedure is rejected because of a “pre-existing condition”. First ask for the letter and the clause. Then check your proposal form and the medical records: if the condition was first diagnosed after your policy started, or after the waiting period ended, say so and attach the reports. If the insurer still refuses, send a written grievance, then a Bima Bharosa complaint, and then the Ombudsman, keeping every reply.

Mistakes to avoid

Hiding a known condition when buying the policy. It is the single most common reason a genuine claim fails later.
Accepting a verbal “no” and never asking for it in writing.
Complaining only by phone, with nothing in writing to show later.
Missing the one-year limit for the Ombudsman.
Throwing away bills, reports and discharge papers. Keep them for years.

Documents to keep ready

Policy document and renewal receipts
Claim form, claim number and the insurer’s letters
Hospital bills, discharge summary, prescriptions and test reports
Your proposal form and earlier medical records
Copies of every complaint and reply, with dates

Sources

Published: 3 November 2026. This is general information, not legal advice. Several figures here come from reports of IRDAI circulars and regulations, and rules and limits can change, so check the latest IRDAI notice and your own policy wording. If the amount is large, consider talking to a consumer-law adviser.