What to Do If Your Health Insurance Claim Is Denied?

If your health insurance claim is denied, start by reviewing the insurer’s claim decision/repudiation letter to understand why the claim was rejected. It must state reasons with policy clauses. Once you identify the issue, gather all necessary paperwork and contact your insurer’s grievance redressal officer for clarification. You have the right to appeal the decision, and in many cases, claims get approved after correction or follow-up. If unresolved within 15 days, escalate via IRDAI’s Bima Bharosa (IGMS) and, if needed, the Insurance Ombudsman.

If you’ve ever filed a health insurance claim, you probably expected the process to be smooth. Except sometimes, your insurer comes back with a cold, confusing claim denial. No reimbursement, just technical jargon.

Whether it’s a cashless claim denial, missing paperwork, or a vague reason like “hospitalisation not required”, the system can feel stacked against you. However, here's the good news: you have rights, and IRDAI lays out a clear escalation path.

At Ditto, we’ve guided over 500 policyholders through claims, appeals, and even Ombudsman cases every month, so we know that denial isn’t always the end of the road. 

In this guide, we’ll break down why claims get denied, what immediate steps you should take, how to strengthen your appeal, and the official IRDAI rules that work in your favour. By the end, you’ll know exactly how to turn a denial into an approval, and how to avoid the same headache in the future.

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Why Was My Health Insurance Claim Denied? 

Health insurance claims can be denied for several reasons, even if you have a comprehensive policy. 

Common causes include filing claims during waiting periods (such as the 30-day initial wait or wait for specific treatments (up to 2 years) and pre-existing conditions (up to 3 years)), treatments falling under permanent exclusions (such as cosmetic or fertility procedures), missing or incorrect documentation, or providing an incomplete or inaccurate medical history. 

Other issues, such as unnecessary hospitalizations, receiving care at blacklisted hospitals, and policy lapses, can also lead to rejections.

To avoid these setbacks, it’s crucial to thoroughly understand your policy and review waiting periods, exclusions, and required documents in advance. 

If you want to learn more about this in detail, you can check out our article on Reasons Why Your Health Insurance Claim Was Denied. 

For now, let’s dive into the steps you can take after your claim has been denied. 

Need help with a denied claim? Our advisors at Ditto can walk you through your next steps, from understanding the reason to helping you file an appeal.

How to Appeal a Denied Health Insurance Claim?

The appeals process is designed to give you a fair shot at reversing the decision. Here’s how to go about it the right way:

Understand Why It Was Denied

Start by reviewing the claim rejection letter from your insurer. According to IRDAI guidelines, insurers must clearly state the reason for rejection, along with the relevant policy clause.

Why this matters: You can’t fix what you don’t understand. Knowing the exact reason helps you build a focused appeal.

Re-Submit as a Reimbursement Claim (if applicable)

If your cashless claim was denied, don’t panic, as it’s not a full rejection. You can still submit a reimbursement claim by providing all necessary documents after treatment.

Include discharge summary, bills, prescriptions, investigation reports, ID proof, and bank details.

Note: Reimbursement claims can also be rejected if documentation is missing or the medical justification is weak, so be thorough.

Escalate to the Grievance Redressal Officer (GRO)

If your claim continues to be denied or remains unresolved, escalate directly to the Grievance Redressal Officer (GRO) of your insurance company.

Send a detailed email explaining:

• Your policy and claim details
• Why you believe the claim is valid
• Any supporting documents and medical justifications

Most insurers list their GRO contact details on their website. You can also find a consolidated list here.

Note: GROs are mandated to respond within 15 days. If you don't receive a satisfactory reply, move to the next step.

Register a Complaint on IRDAI’s Bima Bharosa Platform

If the insurer doesn’t resolve your issue through the GRO, escalate it via IRDAI’s Integrated Grievance Management System (IGMS), also known as Bima Bharosa.

Here, you can register complaints, obtain token numbers, and track the status of your complaint. If the insurer doesn’t resolve within the stipulated time (around 15 days), you can move to the Ombudsman.

IRDAI may take enforcement action (including monetary penalties/orders) for regulatory non-compliance, including breaches of claim-settlement timelines.

You can use this if your insurer misses claim settlement timelines, denies without a valid explanation, or ignores your grievance.

If the issue still isn’t resolved...

Approach the Insurance Ombudsman

As a final escalation step, you can file a complaint with the Insurance Ombudsman. It is an independent authority that resolves disputes between insurers and customers at no cost to either party.

Timeline: 2 to 6 months, depending on the location and complexity of your case.

Ditto’s Tip: Include all relevant documents, correspondence with the insurer, and your GRO complaint details.

What the IRDAI says about Claim Denials The Insurance Regulatory and Development Authority of India (IRDAI) has laid out clear timelines and transparency guidelines for insurers: a) Claims must be processed within 30 days of receiving the last required document b) If further investigation is needed, insurers get up to 45 days c) Delays attract interest at 2% above the bank rate d) All denials must be clearly explained, citing the exact policy clause e) Grievances should be resolved within 15 days; unresolved cases can be escalated on Bima Bharosa (IGMS) and, thereafter, to the Insurance Ombudsman. f) Policyholders can register and track complaints online on IRDAI’s Bima Bharosa (IGMS) portal. Knowing these rules gives you leverage during appeals and escalations.

Now, let’s break down how you can make sure your appeal is undeniable. 

How to Strengthen Your Appeal: Ditto’s Tips

A weak appeal can lead to another rejection, so with the help of our Claims Manager, Akshat, we curated this list for you. 

Here’s how to make your appeal as strong as possible:

1) Get a medical justification

Ask your doctor to write a letter explaining why the treatment was medically necessary. This helps show that it wasn’t optional or cosmetic; it was essential. 

Let’s understand this better with the help of two scenarios. 

Scenario 1: Claims for hospitalisation due to fever, dengue, or malaria are sometimes denied with the reasoning that hospitalisation wasn’t medically required. In such cases, a treating doctor’s certificate (TDC) explaining the necessity of admission can make a big difference. 

Scenario 2: If your past medical records are unavailable, you’ll need a certificate from your doctor stating when the condition was first diagnosed and how long it has existed. This helps establish medical history and the necessity for treatment.

2) Submit complete documentation

Include all relevant records such as Indoor case papers, medical test reports, doctor’s prescriptions, hospital bills, and discharge summaries, among other things. Missing paperwork, even at this stage, is one of the top reasons appeals get rejected. 

3) Be specific and to the point.

In your (appeal letter or an email to the gro), you should clearly explain what the treatment was, why it was needed, and why you believe your claim should be approved. 

Pro Tip: Avoid vague or emotional language and stick to facts and timelines.

4) Stay organised and follow up.

You should track everything, including dates of communication, names of people you spoke to, and reference numbers. Follow up regularly and always get things in writing. 

Note: If the reply from the insurer is unsatisfactory or not received within the prescribed time, policyholders may approach the Insurance Ombudsman under the 2017 Rules.

What If the Appeal Is Still Denied?

In the rarest of rare cases where the insurer and even the insurance ombudsman don’t rule in your favour, but you’re sure your claim is correct, you have one more option. 

Under the Consumer Protection Act, 2019, health insurance falls under the category of “services,” which means that unfair claim denials can be legally challenged. Consumer courts (District, State, or National Commissions, depending on the claim amount) have the authority to direct insurers to honour valid claims, pay compensation for delays, and even impose penalties for deficiency of service.

Of course, litigation can be time-consuming and effort-intensive, but it remains the last resort when all other escalation mechanisms have failed.

How to Avoid Denials in the Future?

Let’s be honest, no one enjoys dealing with paperwork, especially during a medical emergency. This is why we bring to you a list of a few simple habits that can go a long way in ensuring your future claims proceed smoothly.

Here’s what you can do:

1) Get pre-authorisation for planned treatments

For surgeries or non-emergency hospitalisations, always check if your insurer requires pre-approval. It’s one of the most common reasons for claim rejection.

2) Stick to the network hospitals.

Choosing a network hospital makes cashless claims much smoother and lowers the chance of disputes later.

3) Keep every document

Save all medical paperwork, even the ones that seem minor, such as test results, doctor’s prescriptions, hospital bills, and discharge summaries. Having complete documentation makes your claim stronger and less likely to be denied.

4) Know your policy

Read your policy document (yes, that PDF in your inbox). Know what’s covered, what’s excluded, and any waiting periods. 

5) Keep your insurer informed about new diagnosis or ailments

If you’re ever diagnosed with something always ensure that you immediately inform your insurer so that you can get an acknowledgement proof. This helps avoid hassle during potential future claims. 

Why Choose Ditto for Health Insurance?

At Ditto, our experienced team of claims managers is dedicated to going above and beyond to ensure a seamless experience, along with a stress-free claims process with personalized support every step of the way. 

If you need assistance with a claim, please reach out to us now. 

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Conclusion

A denied claim isn’t final, it’s just a hurdle. With the proper paperwork, medical justification, and awareness of IRDAI timelines, you can get many rejections reversed. And even if your insurer won’t budge, you still have escalation routes from the Ombudsman to IRDAI’s grievance system.

So don’t give up at the first “no.” Instead, treat it as the start of the process. And if you’d rather not navigate the maze alone, chat with a Ditto advisor, and we’ll help you appeal, escalate, and secure the payout you deserve.

Still unsure? Book a free call with Ditto’s experts to find the perfect plan for you.

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