Claim rejections are more common than they should be — and many are wrongful. Here is the exact process to push back, escalate, and in most cases, get your money.
First: understand why it was rejected
Insurers are required to give a written reason for every rejection. Read it carefully. Common reasons include:
- Non-disclosure or misrepresentation of pre-existing conditions at the time of buying
- Treatment of a condition during the waiting period
- Treatment not medically necessary (insurer's opinion)
- Specific exclusion in the policy
- Room rent sub-limit triggered proportional deductions
- Documentation incomplete or inconsistent
The reason matters because your counter-argument depends entirely on it. A waiting-period rejection is fought differently from a "not medically necessary" rejection.
Step 1: Gather your documents
Before anything else, collect: the original policy document, the claim rejection letter, all hospitalisation records (discharge summary, doctor's notes, test reports, prescriptions), all bills and receipts, and any prior correspondence with the insurer or TPA.
If you're missing hospital documents, contact the hospital's billing or medical records department — they are required to provide copies.
Step 2: Write a formal grievance to the insurer
Every insurer has a Grievance Redressal Officer (GRO). Send a written complaint — by email with read receipt, or registered post — to the GRO, enclosing your full documentation and clearly stating why you believe the rejection was incorrect. Reference the specific policy clause if possible.
The insurer is required by IRDAI regulation to respond within 15 days. If they don't, or if you're unsatisfied with their response, escalate to Step 3.
Step 3: Escalate to IRDAI's IGMS portal
The Insurance Regulatory and Development Authority of India (IRDAI) runs the Integrated Grievance Management System (IGMS) at igms.irda.gov.in. Register your complaint here with all documentation. The insurer is required to resolve IRDAI-registered complaints within a defined timeline — and their compliance is tracked.
This step alone resolves a significant percentage of wrongful rejections. Insurers tend to reconsider when a regulator is watching.
Step 4: Insurance Ombudsman
If the IGMS process doesn't resolve it, approach the Insurance Ombudsman in your region. There are 17 Ombudsman offices across India, covering specific states. The process is free, and the Ombudsman's decision is binding on the insurer for amounts up to ₹30 lakh.
You must approach the Ombudsman within one year of the final rejection by the insurer.
Step 5: Consumer Forum or Civil Court
For amounts above ₹30 lakh, or if the Ombudsman rules against you and you believe it's wrong, you can file a complaint at the District Consumer Disputes Redressal Commission under the Consumer Protection Act, 2019. This is more time-consuming but has resulted in significant awards — including penalty and interest — against insurers for wrongful rejections.
The most important thing
Don't give up at the first rejection letter. A significant portion of claim rejections are disputed and overturned — especially those citing "non-disclosure" for conditions the policyholder genuinely didn't know they had, or "not medically necessary" for treatments that any reasonable doctor would prescribe.
If you're currently dealing with a rejection and want help working through the process, reach out directly. I've helped clients recover claims that were initially turned down flat.