A rejection letter is not the end. Many rejections are reversed on appeal - especially those based on vague "non-disclosure" or "not medically necessary" grounds.
Common rejection reasons and how to respond
- Pre-existing disease / non-disclosure: insurers must show the condition existed and was material. After 5 years of continuous coverage (the moratorium period under IRDAI rules, earlier 8 years), a claim can't be contested on non-disclosure except for proven fraud.
- Waiting period: check the dates - waiting periods count from the first policy with continuous renewal, including portability.
- "Hospitalisation not required" / OPD treatment: get the treating doctor's certificate explaining why admission was necessary.
- Day-care procedure exclusions: many procedures under 24 hours are covered as day-care.
- Documents missing: submit them - the claim should be reconsidered.
- Room rent capping and proportionate deduction: check the policy wording; IRDAI rules limit proportionate deductions on certain charges.
The path
- Write to the insurer's grievance officer with the claim number, the reason given, your reply point by point, and documents. The insurer must respond within 14 days (IRDAI grievance guidelines).
- Bima Bharosa (IRDAI's grievance portal) if the reply is unsatisfactory.
- Insurance Ombudsman: free, for claims up to ₹50 lakh, after the insurer's reply or 30 days without one, and within 1 year of the insurer's final reply. File online on the CIO portal.
- Consumer commission (e-Jagriti) as an alternative or after.
Write your appeal - paste the rejection letter and get a clause-by-clause reply and the Ombudsman complaint.