By Hari Kotian (IRDAI registration number 0149161D) · Updated 7 October 2026
If your health insurance claim was rejected or paid only in part, start with the insurer’s written reason. Compare it with your policy wording, identify what evidence addresses that reason, and submit a dated grievance through the insurer’s current channel. A rejection is not automatically wrong, and an appeal does not guarantee payment.
A cashless pre-authorization denial at a hospital and a final decision on a reimbursement claim are different events. Ask whether the insurer declined cashless authorization, requested more clinical information, rejected the claim after assessment, or approved only part of the amount. The written reason and policy terms determine what to challenge.
Ask the hospital insurance desk and insurer/TPA for the authorization reference, exact reason, missing information if any, and whether the request can be reconsidered with additional records. Confirm with the insurer how a reimbursement claim would be submitted if you pay directly.
Request the final written decision, the relevant policy wording, a calculation or deduction breakdown, and the records the insurer relied on. Compare each point with your submitted claim before responding.
Do not postpone urgent medical care while trying to resolve a cashless authorization. Discuss care and payment options with the treating provider; use the insurer’s verified channel for claim questions.
The insurer should explain its decision in writing and connect a denial to the applicable policy conditions. These examples are prompts for reviewing the letter, not a determination that the insurer is right or wrong.
| Stated reason | What to check | Possible supporting records |
|---|---|---|
| Waiting period or exclusion | The policy schedule, wording, endorsements, and dates relevant to the treatment or condition. | Policy copy, prior insurer/portability records if applicable, treatment timeline. |
| Pre-existing condition or disclosure | The exact proposal question, answer recorded, policy clause, and stated connection to the treatment. | Proposal copy, medical records, prescription history, and the insurer’s written query/decision. |
| Medical necessity or treatment details | Which clinical information the insurer says is missing or inconsistent. | Treating doctor’s notes, discharge summary, investigation reports, prescriptions, and relevant clinical explanation. |
| Sub-limit, co-pay, deductible, or non-payable item | The amount claimed, the calculation applied, and the policy provision for each deduction. | Itemized bills, payment receipts, policy wording, and the insurer’s settlement calculation. |
| Missing or late documents | The insurer’s dated request, delivery, deadline, and whether each requested item was provided. | Submission receipts, portal screenshots, emails, courier tracking, or a copy of the missing record. |
Ask for the exact policy condition, reason for denial or deduction, and a clear list of any document the insurer still needs. For a health claim, IRDAI’s published health-insurance guidance says a denial communication should state the reasons and refer to corresponding policy conditions; check current IRDAI requirements and policy wording.
Read the schedule, customer information sheet, full policy wording, and endorsements. Note the clause number and the insurer’s explanation. Do not rely on a brochure or a verbal explanation if the contract wording is different.
Arrange records in the same order as the denial reasons. Give files simple labels and keep a copy of each document and proof of submission. Avoid sending unrelated medical records or sensitive information that does not address the issue.
Use the Grievance Redressal Officer (GRO) or other official complaint channel listed by the insurer. State the claim reference, timeline, reason you dispute, evidence attached, and exact action requested. Keep the acknowledgement and any ticket number.
If the response does not resolve the issue, read the current IRDAI Bima Bharosa process and the Council for Insurance Ombudsmen procedure. Their roles and eligibility differ; confirm the applicable filing dates and conditions for your case.
Keep your grievance factual and connect every disputed point to a record. This outline is for organizing a letter; adapt it to your circumstances and the insurer’s instructions.
Do not state facts you cannot support or alter medical documents. Avoid sharing passwords, OTPs, or bank credentials.
Download the health claim document checklist →Keep the date you sent the grievance, the insurer’s acknowledgement, and each response. IRDAI’s grievance information states an insurer should resolve a grievance within two weeks. The Council for Insurance Ombudsmen describes a separate eligibility path after an unsatisfactory insurer response or no response within 30 days, with a filing period and other conditions. These are different stages; check the current official instructions instead of assuming one deadline applies to every route.
IRDAI’s portal allows policyholders to register and track grievances. IRDAI warns that Bima Bharosa does not ask policyholders to pay money to receive claim proceeds. Use the verified official Bima Bharosa portal.
The Council currently describes a ₹50 lakh value limit including expenses, a one-year filing period in specified situations, and other conditions. Read the Insurance Ombudsman eligibility and filing guide and the current CIO procedure.
Official references: IRDAI grievance cell, IRDAI health-insurance FAQs, and the CIO complaint procedure. Check official pages for updates before acting.
Ask the insurer for the written decision, the exact policy condition it relied on, and the list of records considered or still required. Keep the claim reference and submission receipts before you prepare a focused grievance.
Not necessarily. A pre-authorization decision concerns cashless approval at that point in treatment. Ask the insurer or TPA what the decision means, whether additional records can be submitted, and what process applies if you pay and submit a reimbursement claim. Coverage still depends on the policy and facts.
Commonly useful records include the policy schedule and wording, claim form and reference, denial or short-payment letter, discharge summary, prescriptions, investigation reports, itemized bills, payment receipts, and insurer/TPA correspondence. Submit only documents relevant to the stated reason and confirm the insurer’s checklist.
IRDAI’s grievance information says an insurer should resolve a grievance within two weeks. The Council for Insurance Ombudsmen separately describes its eligibility route after an unsatisfactory reply or no response within 30 days. These refer to different stages; check both official procedures and your case dates.
IRDAI Bima Bharosa is a grievance registration and tracking channel. The Insurance Ombudsman is a separate forum with eligibility, territorial jurisdiction, value, and filing-time requirements. Review the official instructions before choosing a route.
No. The insurer or eligible complaint forum decides the case under the policy, evidence, and applicable rules. An appeal organizes your disagreement and supporting records; it cannot promise a reversal.
Written by Hari Kotian, Insurance Support (IRDAI registration number 0149161D). Last reviewed 7 October 2026. This guide is general information, not legal or medical advice. The policy, case facts, and current official procedures determine the available options.