Your Claim Got Rejected: What to Do Next
A claim rejection is not the end. Many rejected claims are reversed on appeal — through the insurer's grievance process, the IRDAI ombudsman, or consumer court. The key is acting quickly, understanding the exact rejection reason, and building your case with proper documentation.
IRDAI data shows that approximately 20–30% of rejected claims are reversed when policyholders escalate through proper channels. Don't accept a rejection without questioning it.
Back to: Health insurance claims guide
Step 1: Understand the Rejection (Day 1–3)
Get the rejection letter
- Every rejection must come with a written rejection letter stating specific reasons
- If you only received a verbal denial, request the written rejection — this is your right under IRDAI guidelines
- The rejection letter should reference specific policy clauses
Common rejection reasons:
| Reason | What It Means | Reversible? |
|---|---|---|
| Pre-existing disease not disclosed | A condition existed before the policy that wasn't declared | Difficult unless you can prove non-awareness |
| Waiting period not completed | Treatment for a condition within the waiting period | Usually not reversible |
| Treatment not covered / exclusion | The specific treatment is excluded from the plan | Depends on plan interpretation |
| Sub-limit exceeded | Claim exceeds the plan's sub-limit for that category | Partial payment should be made; dispute the rest |
| Room rent capping applied | Proportionate deduction because room exceeded plan limits | Usually correct; verify calculation |
| Policy lapsed / premium not paid | Premium wasn't paid before the claim | Reversible if within grace period |
| Documentation incomplete | Required documents were not submitted | Easily fixable — resubmit with complete docs |
| Non-network hospital (cashless denied) | Hospital isn't in the insurer's network | Cashless denied, but reimbursement should work |
Step 2: Gather Your Evidence (Day 3–10)
Build your case file:
- Rejection letter from the insurer (with specific reasons)
- Policy document — highlight the relevant coverage clauses
- Medical records — discharge summary, doctor's notes, investigation reports
- Claim submission documents — copies of everything you submitted
- Previous correspondence with the insurer (emails, call recordings if any)
- Supporting medical opinions — if the rejection is based on medical grounds, get a second doctor's opinion in writing
Key documents for specific rejection types:
| Rejection Type | Evidence to Gather |
|---|---|
| Non-disclosure of PED | Medical records showing you were unaware of the condition; doctor's letter confirming diagnosis date |
| Treatment exclusion | Medical literature showing the treatment falls under covered categories; doctor's justification |
| Sub-limit dispute | Itemized hospital bill; comparison with plan sub-limits; highlight calculation errors |
| Waiting period dispute | Policy inception date; treatment date; calculation showing waiting period has passed |
Step 3: File Internal Grievance (Day 10–15)
Write to the insurer's grievance cell:
Every insurer has a grievance redressal officer. Your complaint should include:
- Subject line: "Grievance — Claim Rejection — Policy No. [NUMBER] — Claim No. [NUMBER]"
- Your details: Name, policy number, claim number, contact information
- Rejection summary: When you claimed, when it was rejected, the stated reason
- Your dispute: Why you believe the rejection is wrong — with specific policy clause references
- Supporting evidence: Attach all documents from your case file
- Relief sought: What you want — full claim settlement, partial settlement, or reconsideration
Sample grievance letter structure:
To: Grievance Redressal Officer, [Insurer Name]
Subject: Grievance — Claim Rejection — Policy [NUMBER]
Dear Sir/Madam,
I am writing to dispute the rejection of my claim [claim number] dated [date].
[State the claim details — hospitalization dates, treatment, amount]
The rejection letter dated [date] states: "[exact rejection reason from letter]"
I disagree with this rejection because:
1. [Your first argument with evidence]
2. [Your second argument with policy clause reference]
I have attached [list of attached documents] to support my case.
I request you to reconsider this rejection and settle my claim of ₹[amount].
[Your name, policy number, contact details]
Use our detailed template: Insurer grievance process template
Timeline:
- Insurer must acknowledge within 3 working days
- Insurer must respond within 15 working days
- If no response or unsatisfactory response, proceed to Step 4
Step 4: Escalate to IRDAI (Day 25–30)
Option A: IGMS (Integrated Grievance Management System)
- File online at igms.irda.gov.in
- IRDAI forwards your complaint to the insurer
- Insurer must respond within 15 days
Option B: IRDAI Ombudsman
- For claims up to ₹50 lakh
- Free of cost — no lawyer needed
- The ombudsman's decision is binding on the insurer (but not on you — you can still go to court)
How to file: Read our detailed guide — IRDAI ombudsman guide
Timeline:
- Ombudsman must pass an order within 3 months of receiving the complaint
- If the order favors you, the insurer must comply within 15 days
Step 5: Consumer Court (If All Else Fails)
If the ombudsman doesn't resolve your issue:
| Claim Amount | Court | Filing Fee |
|---|---|---|
| Up to ₹50 lakh | District Consumer Forum | ₹200–₹5,000 |
| ₹50 lakh – ₹2 crore | State Consumer Commission | ₹5,000–₹25,000 |
| Above ₹2 crore | National Consumer Commission | ₹25,000–₹50,000 |
What you need:
- All documents from Steps 1–4
- Copy of the ombudsman's order (if any)
- A consumer complaint petition (a lawyer can help, or you can file yourself)
Important:
- Consumer courts generally favor policyholders in genuine cases
- Awards can include the claim amount + interest + compensation for mental harassment
- Cases typically take 6–18 months for a hearing
Prevention: How to Avoid Future Rejections
- Disclose everything — pre-existing conditions, lifestyle habits, previous claims
- Read your policy document — understand exclusions, waiting periods, and sub-limits before you need to claim
- Keep all medical records — maintain a health file with all test reports, prescriptions, and hospitalization records
- Inform your insurer promptly — for planned hospitalization, pre-auth 48–72 hours before; for emergencies, within 24 hours
- Use network hospitals — cashless claims have fewer documentation disputes
- Renew on time — a lapsed policy means no coverage
Back to: Health insurance claims guide | IRDAI ombudsman guide
FAQs — Claim Rejection
Can a rejected health insurance claim be reversed?
Yes. Approximately 20–30% of rejected claims are reversed through the insurer's grievance process, IRDAI ombudsman, or consumer court. Don't accept rejection without questioning it.
How do I complain to IRDAI about a rejected claim?
File online at igms.irda.gov.in or approach the IRDAI ombudsman in your region. Both are free of cost and don't require a lawyer.
How long do I have to dispute a claim rejection?
File your grievance with the insurer within 30 days of rejection. For the ombudsman, you have 1 year from the insurer's final response. For consumer court, 2 years.
Can I go to court if the ombudsman rejects my case?
Yes. The ombudsman's decision is binding on the insurer but not on you. You can still approach the consumer court if unsatisfied with the ombudsman's order.
Does NYVO help with claim disputes?
Yes, our advisors review rejection letters and help you build your case for grievance and ombudsman escalation. Book a free consultation.
