Last updated: November 2026. Under IRDAI’s 2024 health insurance master circular, insurers must decide on cashless requests within 1 hour and give final discharge approval within 3 hours of the hospital’s request. Escalating a rejected claim to the Insurance Ombudsman is free.
Few things are more upsetting than paying health insurance premiums for years, going through a hospitalisation, and then receiving a short letter that says your claim has been “repudiated”. Many people assume that is the end of the road. It is not. A large number of rejections are partly or fully reversed when the policyholder challenges them properly.
This guide explains why claims are rejected, the rules that protect you, and the exact steps to challenge a rejection — from the insurer’s grievance cell all the way to the Insurance Ombudsman.
Why health insurance claims get rejected
| Reason given | What it means | Can it be challenged? |
|---|---|---|
| Non-disclosure of a pre-existing disease | The insurer says you hid an illness when buying the policy. | Often yes — especially if the condition is unrelated, was undiagnosed, or the policy has passed the 5-year moratorium. |
| Waiting period not completed | Specific illnesses or pre-existing conditions are covered only after a waiting period. | Yes, if the insurer counted the period wrongly or ignored portability credit. |
| Permanent exclusion | The treatment is listed as not covered (for example, cosmetic surgery). | Usually difficult, unless the treatment was medically necessary. |
| Hospitalisation “not required” | The insurer claims you could have been treated as an outpatient. | Often yes, with the treating doctor’s written justification. |
| Less than 24 hours in hospital | Standard claims require 24-hour admission. | Yes, if the procedure is a listed day-care treatment. |
| Missing documents | Bills, reports or discharge summary not submitted. | Yes — simply submit the documents. |
| Partial payment / deductions | Room-rent limits, “non-payable items” or proportionate deductions. | Sometimes, if the deductions do not match policy terms. |
IRDAI rules that protect you
- Reasons in writing: the insurer must clearly state why a claim is rejected, quoting the relevant policy clause.
- Moratorium period: after 5 years (60 months) of continuous coverage, an insurer cannot reject a claim on the ground of non-disclosure or misrepresentation, except in cases of proven fraud. Years with a previous insurer count if you ported the policy.
- Pre-existing disease waiting period: capped at a maximum of 3 years for policies sold under the current rules.
- Cashless timelines: 1 hour to decide on a cashless request, 3 hours for final discharge authorisation. If the delay exceeds the limit, any extra hospital charges should be borne by the insurer.
- Claims review: IRDAI expects insurers to have a claims review committee look at a claim before it is rejected.
Rules evolve, so check the latest circulars on irdai.gov.in if your case turns on a specific provision.
7 steps to challenge a rejected claim
Step 1: Get the rejection letter and the full policy wording
Ask the insurer or TPA for the written rejection letter if you only received an SMS. Download your full policy wording (not just the brochure) and the policy schedule. Find the exact clause they used.
Step 2: Collect all medical documents
- Discharge summary and all bills with itemised breakdowns
- Investigation reports, prescriptions and pharmacy bills
- Doctor’s consultation notes, including the first time the condition was diagnosed
- Your proposal form (what you declared when buying the policy) and previous policy copies if you ported
Step 3: Get a letter from your treating doctor
This is often the most powerful document. Ask the doctor to explain in writing why hospitalisation was medically necessary, when the condition first started, and — if non-disclosure is alleged — that the current illness is unrelated to the condition the insurer is pointing to.
Step 4: File a written grievance with the insurer
Write to the insurer’s grievance redressal officer (details are on its website and your policy document). Keep it factual:
- Policy number, claim number and dates of hospitalisation
- The reason the insurer gave and why it is wrong, point by point
- The policy clauses and IRDAI rules that support you (for example, the 5-year moratorium)
- The amount you are claiming and a request for a written response
Save the acknowledgement or grievance number. Insurers are generally expected to resolve grievances within about two weeks.
Step 5: Escalate to IRDAI’s Bima Bharosa portal
If the insurer does not respond satisfactorily, register a complaint on IRDAI’s Bima Bharosa grievance system at bimabharosa.irdai.gov.in, or call IRDAI’s toll-free number 155255. Your complaint is forwarded to the insurer and tracked by the regulator.
Step 6: Approach the Insurance Ombudsman
The Insurance Ombudsman is an independent, free forum for individual policyholders. You can approach it when:
- The insurer rejected your grievance, gave an unsatisfactory reply, or did not reply within 30 days; and
- You file within one year of the insurer’s final reply; and
- The total claim, including expenses, is within the ombudsman’s limit (currently ₹50 lakh); and
- The same matter is not pending in a court or consumer forum.
Complaints can be filed online through the Council for Insurance Ombudsmen’s portal (cioins.co.in) or at the ombudsman office for your area. You do not need a lawyer. The ombudsman generally aims to pass an award within about three months of receiving all requirements, and the insurer must comply within 30 days once you accept it.
Step 7: Consumer commission (last resort)
If the ombudsman route does not work or your claim is larger, you can file a complaint before the District Consumer Disputes Redressal Commission. Filing is possible online through the e-Daakhil portal. Consumer commissions have frequently ruled in favour of policyholders in non-disclosure and “hospitalisation not required” cases.
Escalation ladder at a glance
| Level | Where | When to move on |
|---|---|---|
| 1. Insurer / TPA | Grievance redressal officer | No reply or unfair reply |
| 2. IRDAI | Bima Bharosa portal, 155255 | Still unresolved |
| 3. Insurance Ombudsman | cioins.co.in or local office | Rejected award or claim above limit |
| 4. Consumer commission | e-Daakhil / District Commission | Final forum before higher courts |
The ladder is similar to the one for banking complaints, which go to the RBI instead. Our guide on complaining to the RBI Ombudsman covers that process.
How to avoid claim rejection in the first place
- Disclose everything on the proposal form — diabetes, blood pressure, thyroid, past surgeries, smoking. A slightly higher premium is far better than a rejected claim.
- Read the waiting periods and sub-limits before buying. Our health insurance comparison explains what to look for.
- Choose a policy without room-rent capping if you can — room-rent limits trigger proportionate deductions on the entire bill.
- Inform the insurer on time: usually before planned admission and within 24 hours of an emergency admission.
- Use network hospitals for cashless treatment where possible.
- Keep every document, and take photos of original bills before submitting them.
- Renew on time so that your waiting periods and moratorium keep counting.
Frequently asked questions
My cashless claim was denied. Does that mean the claim is rejected?
Not necessarily. Cashless can be denied because of incomplete information at the time of admission. You can pay the hospital, then file a reimbursement claim with all documents within the time limit in your policy.
How long does the insurer have to settle a reimbursement claim?
Insurers are expected to settle or reject a claim within 30 days of receiving the last necessary document. Delays beyond the permitted time can attract interest payable to you.
Does the Insurance Ombudsman charge a fee?
No. Filing with the Insurance Ombudsman is free of charge.
Can I complain about a group health policy from my employer?
Yes. As the insured person, you can use the insurer’s grievance process and IRDAI’s portal. Your HR team can also escalate with the insurer or broker on your behalf.
Bottom line
A rejection letter is the insurer’s first answer, not the final one. Gather your documents, get your doctor’s letter, write a clear grievance, and use IRDAI and the Insurance Ombudsman if needed. Persistence and paperwork win more claims than people expect.
Disclaimer: This article is general information, not legal or insurance advice. Policy terms differ between insurers, and IRDAI rules and ombudsman limits can change. Check your policy wording and the latest rules on irdai.gov.in and cioins.co.in. Read our full disclaimer.