Top Reasons for Claim Rejection
- Non-disclosure: Pre-existing disease not declared at time of buying policy — most common reason
- Waiting period: Claiming for condition within 2-4 year waiting period
- Policy exclusion: Treatment not covered — cosmetic surgery, dental, OPD (in most plans)
- Documentation: Missing bills, doctor reports, discharge summary
- Fraudulent claim: Inflated bills, fake receipts detected
- Premium lapse: Policy not active due to missed renewal
📋 Important: You have the right to appeal any insurance rejection. Under IRDAI regulations, insurers must respond to appeals within 15 days. If not satisfied, you can approach the Insurance Ombudsman — free service, decision binding on insurer for claims up to Rs 30 lakh.
📋 Step-by-Step: What to Do When Claim is Rejected
1
Get rejection letter with reason in writing
Insurer must provide written rejection reason. If not received, request formally in writing. You need this for appeal.
2
Review policy document — check if exclusion is valid
Read your policy document carefully. Many rejections cite wrong clauses or misinterpret conditions. If rejection seems wrong — you have grounds to appeal.
3
File internal grievance with insurer
Email/write to insurer's Grievance Redressal Officer (GRO). Insurer must respond in 15 days. Include all documents, policy number, rejection letter.
4
Approach IRDAI Bima Bharosa if insurer doesn't respond
File complaint on IRDAI's Bima Bharosa portal (bimabharosa.irdai.gov.in) or call 155255. IRDAI will mediate with insurer.
5
Insurance Ombudsman — final escalation
File complaint with Insurance Ombudsman in your region (cioins.gov.in). Free service. Decision is binding on insurer for claims up to Rs 30 lakh. Usually resolved in 90 days.
⚠️ Prevent rejection — always disclose everything: When buying health insurance, declare ALL pre-existing conditions — diabetes, BP, thyroid, past surgeries, everything. Insurer may charge slightly higher premium but CANNOT reject claim for disclosed conditions. Non-disclosure is the #1 cause of claim rejection — a few hundred rupees extra premium is much better than a rejected claim of lakhs.
Disclaimer: IRDAI regulations as of 2026. Process may vary by insurer. Consult insurance advisor for complex rejections.