Health Claim Denied? The Legal & Practical Recovery Playbook
By regulation the insurer must provide a written rejection citing the specific policy clause. If they have not, write a formal letter demanding one and keep every communication with dates.
Why claims get rejected
Non-disclosure of pre-existing diseases, incomplete waiting periods, policy exclusions, lapsed policies, delayed intimation, and missing documentation cause most rejections. The insurer must state the reason in writing - demand it if absent.
Step 2: Internal grievance (GRO)
File a formal complaint with the insurer's Grievance Redressal Officer with supporting documents. The insurer must respond within 15 days. This is the mandatory first step before external escalation.
Claim recovery specialists handle appeals through GRO, IRDAI and the Ombudsman, and have recovered over Rs 50 crore for families. See the health insurance claim rejection fight-back guide for free guidance.