Short answer: a rejection is not final. Find the exact ground in the letter, collect the policy, the proposal form, a treating-doctor certificate and the hospital file, write to the insurer's Grievance Redressal Officer, and if the reply does not reverse it, go to the Insurance Ombudsman within one year — it is free and its award binds the insurer. Many rejections on non-disclosure, pre-existing disease and "not medically necessary" are reversed this way.
Every repudiation letter names a reason: non-disclosure, pre-existing disease, waiting period, policy exclusion, not medically necessary, or late intimation. Write it down. Every step after this answers that one ground.
The policy wording with its exclusion list, the proposal form you signed (the insurer must give you a copy), a certificate from your treating doctor stating when the condition was first diagnosed, and the complete hospital file — discharge summary, investigations, bills.
Under IRDAI's 2024 health insurance master circular, after 60 months of continuous cover an insurer cannot reject on non-disclosure unless it proves fraud, and the pre-existing disease waiting period can be no longer than 36 months. Count your years of cover, including portability.
Answer the stated ground with your documents, in writing, and keep the acknowledgement. Insurers are required to resolve a grievance within 14 days.
If the grievance officer does not reverse the decision, register the complaint on Bima Bharosa, IRDAI's grievance portal, so it is logged and tracked by the regulator.
Free, no lawyer needed, for claims up to ₹50 lakh. File within one year of the insurer's final reply — or one month after your last letter if the insurer has not replied. The Ombudsman passes an award within three months of receiving everything, and the award binds the insurer.
Available whatever the policy says. District Commission up to ₹50 lakh, State Commission up to ₹2 crore, National Commission above that. File within two years of the rejection.
Non-disclosure where the condition was diagnosed after the policy began, or where the only evidence is a line in a discharge summary written from what the patient said at admission. Pre-existing disease where the waiting period has already run. "Not medically necessary" where the treating doctor can explain in writing why admission was required. Late intimation where the delay did not actually prevent the insurer assessing the claim.
A cashless claim that is approved but never paid, repudiated after discharge, short-paid after a tariff deduction or closed without intimation is recoverable through the same escalation route, with the TPA in the chain. Medilock's Cashless Recovery desk takes these up for hospitals and is paid only on what is recovered.
Medilock Claim Assistance takes the file up with the insurer for you, through the grievance and Ombudsman routes. Legal fees are 15% plus GST of what is actually settled and received by you. If the claim is finally rejected, you pay nothing.
Read the rejection letter for the exact ground, then ask the insurer in writing for a copy of your proposal form. Most successful challenges answer the stated ground with four documents: the policy wording, the proposal form, a treating-doctor certificate and the hospital file.
Write to the insurer's grievance officer as soon as possible. The Insurance Ombudsman must be approached within one year of the insurer's final reply, and a consumer complaint within two years of the rejection.
Yes. There is no fee and you do not need a lawyer. The Ombudsman hears claims up to ₹50 lakh and its award is binding on the insurer.
Not under IRDAI's 2024 health insurance master circular. After 60 months of continuous cover the policy cannot be contested on non-disclosure or misrepresentation, except for proven fraud.
Yes. Medilock reviews the rejection, tells you whether it is contestable, and takes it up with the insurer. Individuals pay 15% plus GST only on what is actually settled; hospitals use Cashless Recovery.