Bimaclaimo: frequently asked questions
Insurance Claim Appeal
Can a rejected health insurance claim really be reversed?
Often, yes. Many rejections rest on reasons that IRDAI rules limit: 'hospitalisation not required' against the treating doctor's advice, pre-existing disease claims beyond the 36-month look-back or after 60 months of continuous cover, or proportionate deductions on medicines and tests. A written grievance that answers each reason with the policy wording and documents, followed by the Insurance Ombudsman if needed, gets many such claims paid. Some rejections are correct (a genuine exclusion or an undisclosed related illness) and the draft tells you honestly when that is likely.
What do I do first after a claim rejection?
Ask for the rejection reason and deduction sheet in writing, then send a grievance by email to the insurer's Grievance Redressal Officer (the address is on the insurer's website and policy). Insurers are expected to resolve grievances within 14 days. If they reject it or don't reply within 30 days, you can go to the Insurance Ombudsman within 1 year.
What is the Insurance Ombudsman and does it cost anything?
It is a free forum for disputes with insurers in India, for claims up to ₹50 lakh. You file online at cioins.co.in with the office covering your address, after first complaining to the insurer. If you accept its award, the insurer must comply. You don't need a lawyer.
The insurer says 'pre-existing disease' but I declared everything. What now?
Ask for a copy of your proposal form. If you declared the condition, or the illness claimed is unrelated, or the policy has been running for 60 continuous months (counting ported policies), the rejection is weak. The draft builds the rebuttal and a doctor's certificate on when the illness started.
My room was above the limit and they cut the whole bill. Is that allowed?
Only partly. Proportionate deduction may apply to 'associated' charges like doctor and nursing fees, but not to medicines and consumables, implants, tests or ICU charges. Use the free checker on this page to see the most the insurer could deduct.
Does it work for US health insurance denials?
Yes. Choose USA. You get an internal appeal letter that answers the plan's criteria and asks for your claim file, a letter of medical necessity draft for your doctor, and the external review request with deadlines (180 days to appeal, 4 months for external review). Medicare and Medicaid have different steps; the draft notes that if your plan is one of those.
How much does it cost?
₹149 in India or $3 elsewhere for one case: the full appeal pack (letter, doctor's certificate, documents list and deadlines) with 3 revisions, for example to add the clause number once you find it or to write the Ombudsman complaint next. The decoder, deadline planner and deduction checker are free.
Will you send it to the insurer or represent me?
No. You send the letter yourself by email or on the portal. For fraud allegations, very large claims or court cases, use a lawyer - the draft says when.
Is my medical information safe?
Share only what the letter needs. You can replace names and policy numbers with placeholders and fill them in after downloading.