A rejection letter from your insurer is not the end of the matter. It is the start of a process that Indian insurance regulation gives you the right to use — and a significant share of rejections are reversed when policyholders actually use it.
Most people never do. They read the words "claim repudiated", assume the decision is final, and pay the hospital bill themselves. The insurer is counting on exactly that.
This guide walks through the escalation ladder step by step, with the deadlines that apply at each stage and the documents you need.
The short answer
If your health insurance claim was rejected in India, escalate in this order:
- Get the rejection in writing, with the specific policy clause cited.
- File an internal appeal with the insurer's grievance redressal officer. The insurer must respond within 14 days.
- Escalate to IRDAI through the Bima Bharosa portal if the response is unsatisfactory or absent.
- File with the Insurance Ombudsman — free, no lawyer required, within one year of the rejection, for claims up to ₹50 lakh.
- Approach the consumer court if all of the above fail.
Each step matters, because the Ombudsman will ask whether you approached the insurer first.
Step 1: Get the rejection in writing, with a reason
A phone call saying "your claim has been denied" is worth nothing. Under IRDAI rules, the insurer must give you a written repudiation letter stating the specific ground for rejection and the policy clause it relies on.
Ask for it in writing, by email, and keep the email. If they cite a clause, ask for the clause number and the exact wording.
Why this matters: you cannot appeal a reason you have not been told. And insurers who deny claims on weak grounds are often reluctant to commit those grounds to paper. Requesting the written repudiation sometimes resolves the matter by itself.
The letter must also tell you how to escalate. The IRDAI Master Circular on Protection of Policyholders' Interests, 2024 requires the insurer, when it decides against you, to inform you of the route to the Insurance Ombudsman in the same communication.
Step 2: Read the clause they cited, not the letter
The rejection letter is a summary. The clause is the actual argument. Pull out your policy document and read the exact wording of the clause cited. You are looking for one of three things:
- A factual error. The insurer says the condition was pre-existing, but your diagnosis date is after the policy start date. Your own medical records settle this.
- A misapplied clause. The clause covers something other than your situation — for example, a waiting period for a different category of treatment.
- A vague ground with no basis stated. "Not medically necessary" is not an argument unless the insurer explains what medical standard your treatment failed.
Write down the specific mismatch you find. That single sentence becomes the spine of your appeal.
Step 3: File an internal appeal with the grievance cell
Every insurer must have a grievance redressal officer, and their contact details must be on the insurer's website.
Your appeal should contain
- Policy number, claim number and date of rejection
- The clause the insurer cited, quoted exactly
- Why that clause does not apply to your case, in plain language
- The evidence that proves it, referenced by attachment number
- A clear request: reconsider and settle the claim
Attach: the repudiation letter, the policy document, the hospital discharge summary, the treating doctor's notes, prescriptions, diagnostic reports, and all bills.
Deadline: the insurer must resolve the grievance within 14 days of receiving it.
A generic "please reconsider my claim" letter almost always fails. An appeal that quotes the clause and shows exactly why it does not apply is what forces a real review, because someone has to answer the point on record.
Step 4: Escalate to IRDAI through Bima Bharosa
If the insurer does not reply within the deadline, or replies with a rejection you do not accept, take it to the regulator.
Bima Bharosa is IRDAI's online grievance portal (formerly IGMS). You register the complaint, attach the same documents, and the complaint is routed to the insurer with a regulatory record attached to it. You can also use the IRDAI helplines: 155255 or 1800 4254 732.
What this achieves: a Bima Bharosa complaint is tracked and reported. Insurers treat a regulator-logged complaint differently from an ordinary customer email, and a meaningful number of claims are settled at this stage without going further.
Step 5: File with the Insurance Ombudsman
This is the step most people have never heard of, and it is the most powerful one available to an ordinary policyholder.
The Insurance Ombudsman is a free, quasi-judicial forum set up under the Insurance Ombudsman Rules, 2017. No lawyer is needed. You do not pay a fee.
You are eligible if
- The claim amount does not exceed ₹50 lakh
- You approached the insurer first, and either received a rejection or got no reply within one month
- You file within one year of the insurer's rejection
- The same dispute is not already before a court or consumer forum
How to file: submit the complaint to the Ombudsman office with jurisdiction over your location, in person, by post or online through the Council for Insurance Ombudsmen. Include the complaint form, the repudiation letter, your appeal, the insurer's response, the policy document and your medical records.
The outcome: the Ombudsman can direct the insurer to pay the claim, and an award is binding on the insurer. You are not bound by it — if you disagree, you can still go to the consumer court.
The deadline is the thing to watch. One year from the rejection sounds generous, and it passes quickly while you wait for an insurer who has no intention of replying.
Step 6: Consumer court
If the Ombudsman route fails or does not apply — for instance, if your claim exceeds ₹50 lakh — a consumer complaint is available under the Consumer Protection Act, through the e-Jagriti portal. It is slower and usually involves a lawyer, but consumer forums have awarded compensation for deficiency in service on top of the claim amount.
Rejection reasons that are most often overturned
| Reason cited | What to check | Your counter |
|---|---|---|
| Pre-existing disease | Date of first diagnosis vs. policy start date | Medical records showing diagnosis after the policy began |
| Non-disclosure of material facts | Whether the undisclosed condition relates to the treatment claimed | An unrelated condition is not a material fact for this claim |
| Waiting period not completed | How the insurer counted the policy start date, including renewals | Continuous coverage from the original policy, not the latest renewal |
| Not medically necessary | Whether the insurer states a medical basis | Treating doctor's written justification for the line of treatment |
| Treatment excluded under the policy | Exact wording of the exclusion | Your procedure falls outside the exclusion as worded |
| Delay in intimation | Whether the delay caused any prejudice to the insurer | Courts have repeatedly held that genuine claims should not fail on delay alone |
Three rights most policyholders do not know they have
1. The 60-month moratorium. After 60 months of continuous coverage, your insurer can no longer reject a claim or cancel the policy on grounds of non-disclosure or misrepresentation. The only exception is established fraud — which the insurer must actually prove, not merely allege. This was reduced from 96 months by the IRDAI Master Circular on Health Insurance Business, 2024.
2. Cashless timelines. Under the same circular, the insurer must decide on a cashless pre-authorisation request within 1 hour, and issue final discharge authorisation within 3 hours of the hospital's request. If the discharge is delayed past that, additional hospital charges caused by the delay are to be borne by the insurer, not you.
3. No piecemeal document requests. The insurer must ask for all the documents it needs at one go, rather than sending repeated requests that stretch the timeline. A claim delayed by drip-fed document demands is a complaint worth making.
Documents checklist for any appeal
- Written repudiation or rejection letter
- Full policy document, including terms, conditions and exclusions
- All policy renewal records, showing continuous coverage
- Hospital discharge summary
- Treating doctor's notes and a written justification for the treatment
- All prescriptions and diagnostic reports
- Complete hospital bills and payment receipts
- Every email and letter exchanged with the insurer
- Claim form and claim number
Keep everything as PDFs, named clearly. You will submit the same set three or four times as the matter escalates.
Timeline at a glance
| Stage | Who decides | Time limit |
|---|---|---|
| Grievance to insurer | Insurer's grievance officer | Resolve within 14 days |
| Bima Bharosa complaint | IRDAI, routed to insurer | Track on the portal |
| Insurance Ombudsman | Ombudsman | File within 1 year of rejection |
| Consumer court | Consumer commission | Generally within 2 years of cause of action |
Frequently asked questions
Can a rejected health insurance claim be reopened?
Yes. A rejection is the insurer's decision, not a final ruling. You can appeal internally, escalate to IRDAI, and file with the Insurance Ombudsman, who can direct the insurer to pay.
How long do I have to appeal a rejected claim?
There is no fixed limit for the internal appeal, but the Insurance Ombudsman must be approached within one year of the insurer's rejection. File the internal appeal promptly so that this deadline is not at risk.
Does filing with the Insurance Ombudsman cost anything?
No. The process is free and you do not need a lawyer.
What is the maximum claim the Ombudsman can decide?
Complaints where the loss payable under the policy does not exceed ₹50 lakh.
Can the insurer reject my claim for something I did not disclose years ago?
Not after 60 months of continuous coverage, unless the insurer proves fraud. Before that period, disclosure disputes turn on whether the undisclosed fact was material to the claim.
The hospital refused cashless and asked me to pay. What now?
Pay and file a reimbursement claim, keeping every bill and the hospital's written reason for refusing cashless. Denial of cashless does not mean denial of the claim.
Is an IRDAI complaint the same as an Ombudsman complaint?
No. IRDAI's Bima Bharosa routes your grievance back to the insurer with a regulatory record. The Ombudsman is a separate forum that can issue an award binding on the insurer.
What if my claim is more than ₹50 lakh?
The Ombudsman route is unavailable. A consumer complaint or civil suit is the remaining option.
Not sure what your rejection letter actually says?
Upload it and ClaimRights identifies the ground cited, maps it to the applicable IRDAI regulation, and drafts the internal appeal, IRDAI complaint and Ombudsman submission for your case.
Check my rejection letter →This article is general information, not legal advice. Regulatory timelines and limits change — verify current requirements on the IRDAI website before filing. Last reviewed: 23 September 2026.