A rejection letter is not the end of the claim. It is the start of a process with fixed timelines, and a large share of rejections in India are overturned when they are properly challenged.
If you have just received a rejection letter from your insurer, the most useful thing to know is this: a rejection is a decision by one department of one company, and there are four places above it where that decision can be reviewed. Most people never use any of them.Step 1 — Read the letter for the ground, not the toneSomewhere in it there is a specific reason. It will usually be one of:Non-disclosure — you did not declare a condition when you took the policy.Pre-existing disease — the illness existed before the policy, within the waiting period.Waiting period — the policy or that specific ailment had not completed its waiting period.Policy exclusion — the treatment is excluded by name.Not medically necessary — the insurer says admission was not required.Late intimation — you told them too late.Write the ground down. Everything from here answers that one ground.Step 2 — Collect four documentsAlmost every successful challenge rests on these:The policy document, with the wording and the exclusion list. Not the brochure — the actual policy.The proposal form you signed. Ask the insurer for a copy. You are entitled to it. If an agent filled it in, that matters.A certificate from your treating doctor stating the date you were first diagnosed and on what basis.The complete hospital file — discharge summary, investigations, prescriptions, bills.Step 3 — Know which arguments actually workOn non-disclosure: the insurer must show you knew about the condition and that it was material. If you were diagnosed after the policy started, there was nothing to disclose. A line in a discharge summary saying "diabetic since 8 years" is what a junior doctor wrote down from what you said in casualty — it is not a medical record of diagnosis, and a treating doctor's certificate carries more weight.On pre-existing disease: check how long the policy has run. Once the pre-existing disease waiting period is complete — often two to four years — a pre-existing condition is covered. Insurers do reject inside that window on policies that are well past it.On not medically necessary: this one is answered by the treating doctor, in writing, explaining why admission was clinically required. Insurers rarely maintain this ground against a clear clinical note.On late intimation: delay alone is usually not enough to repudiate a genuine claim, particularly where the insurer's ability to assess it was not actually prejudiced.Step 4 — Escalate in the right orderSkipping steps costs you time, because each forum will ask whether you used the one below it.The insurer's Grievance Redressal Officer. Every insurer publishes one. They must respond within 15 days.Bima Bharosa, IRDAI's grievance portal. Logged and tracked.The Insurance Ombudsman. Free, no lawyer required, decisions are binding on the insurer. There is a monetary limit and a time limit — generally one year from the insurer's final rejection, which is the deadline most people miss.Consumer court. Available whatever the contract says.What this costsNothing, if you do it yourself, beyond your time and the documents. The Ombudsman charges no fee and does not require a lawyer.If you would rather not run it, that is what our Claim Assistance service does. Our fee is 15% of what is actually settled and reaches you, plus GST. If the claim is finally rejected and you receive nothing, you pay us nothing. We also tell you at the start if we think the claim will not stand up, because there is no point either of us spending months on a file that cannot win.The deadline to watchOne year from the insurer's final rejection for the Ombudsman. If your letter is older than that, read it again today.This article is general information, not legal advice. Your policy wording governs your claim.