Was Your Health Insurance Claim Rejected? File A Complaint With The Insurance Ombudsman

Pragya Pathak

Author

Updated: 28-01-2025 at 7:40 AM

What To Do When Health Insurance Claim Is Rejected?

The feeling of safety and security is one of the most basic feelings that we all desire to have and experience in our lives and one of the ways of achieving the same is by investing in health insurance policies. Insurance is one of the shields that allows us to protect ourselves and the people we care about from the uncertainties of life, but what is to be done if your policy claim is rejected?

There are various types of insurance and one of those is health insurance. According to a report of 2022, around 52 crore people invest in health insurance schemes and policies which represents how crucial it is for people to have a sturdy shield for their lives.

However, when one decides to invest in a health insurance policy, they have to cross-check and fulfil the eligibility criteria of one. Recently, there have been many cases wherein people’s health insurance claims have been rejected due to baseless reasons like the insurer’s opinions on whether hospitalisation is required or not in contrast to the medical professional’s advice. Through this article, we will learn what to do if your health insurance claim is also rejected without any proper reason.

What To Do If One’s Insurance Claim Is Rejected?

According to the Insurance Regulatory and Development Authority of India (IRDAI), insurance providers cannot reject a policyholder’s claim if they have been paying the premium of their insurance policy for the last 8 years, also known as the moratorium period.

In instances where one’s health insurance claims get rejected, one can take the following actions against their insurance provider:

File a complaint directly to the IRDAI’S Bima Bharosa Portal.
Dial 1800-4254-732.

In case, the individual receives no update about their filed complaint even after 15 days, they have the right to approach the Insurance Ombudsman as per the provisions mentioned in the Insurance Ombudsman Rules of 2017.

What Is The Insurance Ombudsman?

The government of India established the Insurance Ombudsman to provide a way for the policyholders to get whatever issues they might be facing resolved as efficiently and cost-effectively as possible.

At present, there are around 17 Insurance Ombudsman offices spread across the nation. As per the Insurance Ombudsman Rules of 2017, an individual can approach the Ombudsman only upon certain conditions:

If the individual receives no update about their filed complaint to the insurance provider even after 15 days.
The claim doesn’t amount to more than Rs. 50 lakh.

How To File A Complaint With The Insurance Ombudsman?

Complainants must write their complaint and get it signed by the policyholder, claimant, legal heirs, or assignee, attach the supporting documents, and send the complaint through mail, online website, or post it to their office.

Documents that the complainant needs to attach and submit are mentioned below for one’s reference:

Copy of the policy
Copies of all old policies for the last 48 months before the claim was rejected
Denial letter/Partial settlement by the Insurance provider
A representation letter was sent to the Insurance provider

Conclusion

Insurance Ombudsman was established with the sole purpose of resolving policyholder’s issues as quickly and efficiently as possible. All the policyholders are given this and other ways out to make their lives easier and hence, every insurance policyholder is requested to file a complaint as soon as possible.

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