Health insurance claim rejected: what to do, in order

Last checked against the source documents on 4 November 2026. General information, not legal advice.

A rejection letter feels final, but it is the insurer's first answer. India has a set route for disputing it. It costs nothing to use, and you do not need a lawyer for it. The order matters, because a wrong move can close a better option.

1. Read the letter for one thing: the clause

IRDAI's Master Circular on Health Insurance (29 May 2024) says that when a claim is repudiated or partly disallowed, the insurer must give full details, with reference to the specific terms and conditions of your policy (Chapter I, para 17(b)). It also says no claim can be repudiated without approval from the Product Management Committee or its Claims Review Committee (para 17(a)). If your letter is vague, that is your first point.

2. Write to the grievance officer

Send an email, not just a call. The Ombudsman's portal requires a copy of your written complaint to the insurer, so a phone call alone will not count. The Department of Financial Services says insurers must acknowledge a complaint immediately and resolve it within 14 days.

State the policy and claim numbers, the reason given, why you disagree, the amount you want, and that you will escalate if it is not resolved.

3. Complain to IRDAI if it is not resolved

After 14 days, or if the reply is unsatisfactory, go to IRDAI's Bima Bharosa portal at bimabharosa.irdai.gov.in. You can also call 155255 or 1800-4254-732, or email complaints@irdai.gov.in. It is free.

4. File with the Insurance Ombudsman

This is the step with real power. You can file once the insurer has rejected your representation, or has not replied for a month, or has replied and you are not satisfied (Rule 14(3)). You have one year to file. It is free, it can be done online at cioins.co.in, and the award binds the insurer. See our Ombudsman guide.

5. Keep the consumer commission as a backup

Consumer commissions are a real option, generally within two years, with no filing fee up to ₹5 lakh. But the Ombudsman cannot take a matter already pending before or decided by a court or consumer forum (Rule 14(5)), so going there first closes the free route.

What to keep ready

• Rejection letter or settlement advice
• Policy schedule, wording and Customer Information Sheet
• Discharge summary, final bill and investigation reports
• Your written complaint and any reply
• ID and address proof

Reasons you can often push back on

A non-disclosure rejection after 60 months of cover is a strong case. Unexplained deductions are worth challenging. Claims closed for missing documents can run into para 17(c), which says insurers and TPAs shall collect documents from the hospital. Some rejections are correct under the policy, though, so read your exclusions honestly before you spend time on this.