Health Insurance Claim Rejected? Step-by-Step Appeal Guide for India (2026)

Having a health insurance claim rejected during a medical emergency is stressful and unjust. In India, over 12-15% of initial health insurance claims face rejection or short-settlement. However, a rejection is not the final word. With the right documentation and escalation framework under IRDAI guidelines, a significant percentage of rightful claims are successfully overturned.

Step 1: Demand Written Rejection Reasons

Never rely on verbal explanations from the TPA (Third Party Administrator) or hospital desk. Demand the official Repudiation Letter or short-settlement statement in writing, detailing the exact clause invoked.

Step 2: File Grievance with Insurer's Grievance Redressal Officer (GRO)

Insurance companies are mandated by IRDAI to resolve grievances within 14 days. Submit a formal appeal attaching your discharge summary, doctor's certificate clarifying medical necessity, and policy wording proofs.

Step 3: Escalate to IRDAI Bima Bharosa & Insurance Ombudsman

If the insurer upholds the rejection or fails to reply within 30 days, you can lodge a complaint on the IRDAI Bima Bharosa portal or approach the local Insurance Ombudsman (free of cost, binding on the insurer up to Rs. 50 lakhs).