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With the emerging health issues in India, it is suggested that all the individuals should avail health insurance. This would, in turn, help in reducing the financial burden caused to individuals or family members.

Under health insurance, hospitalization expenses, medical expenses, laboratory tests, and other related expenses are covered. When an individual avails health insurance for self or family members, (s)he is authorized to file claims as and when the need arises. 

Many of the policyholders file health insurance claims and receive their claim amount (when accepted by the insurer) into their bank accounts. But there are times when the claim is rejected. This may be due to various reasons given below:

  • Claim raised for treatment is not covered under the policy.
  • Individuals making fraudulent claims.
  • The administrative flaw in filing a claim.
  • Documents required are not provided.

What Should Be Done To Appeal Against Rejected Health Insurance Claims?

Here given are some of the ways through which individuals can appeal against the rejected claims:

  • Re-check & Re-apply: If you have found any mistakes while applying for applications on your own, it is better to re-check and then again apply for a claim. It should be noted that no claims can be re-applied if the health insurance is expired by the given time. If the application gets rejected, the insurer sends a denial letter to the network hospital where every detail is to be read carefully to determine the cause of claim rejection.
  • Approach Ombudsman: Ombudsman helps the policyholders in settling any issues related to insurance complaints. They act as a bridge between the insurer and the policyholders. Individuals can appeal formally through writing to the ombudsman (of their location). 
  • Collect medical bills: Once you are acquainted with the denial reason, collect all the documents such as medical records, policy wordings, medical receipts, etc. These documents can help in appealing against the rejected health insurance claims.
  • Keep track of communications: To appeal against the denied claim, you must keep the record of the conversation. This may act as an evident proof in filing the appeal. Any communication made through emails, letters, messages, and others should be kept safely, which can be used during any critical circumstances. 
  • Take Follow-up: When your appeal regarding the rejected health insurance claim is done, do not forget to follow up with your insurance/insurance-agent about the proceedings of the appeal.

Important Aspects

Here are some of the important aspects that need to be considered to avoid rejection of health insurance claims:

  • Go for online health insurance plans as this will help minimize the mistakes when purchased through offline mode.
  • Read the terms and conditions carefully before buying the health insurance policy.
  • Do not delay in filing the appeal regarding claim settlement, premium dispute, and other issues.
  • Do not forget to mention your policy number, name, address and other relevant details when writing to the insured/ombudsman/insurance agent.
  • It is important to submit the policyholder’s bank account details while filing for the claim. 

What To Do if a Company is Creating Problems For You To File a Claim?

It might happen that some of the insurers might create a problem for policyholders to file a claim. For this, it is required that policyholders should be well aware of the terms and conditions of the health insurance policy. It is suggested that policyholders should follow below-mentioned points in order to minimise problems in the filing of claim:

  • Talk to the insurer and understand their reason(s) for creating a problem. 
  • Consult a lawyer if any mishap arises.
  • Write an email to the IRDAI (Insurance Regulatory and Development Authority).

The main aim of health insurance is to settle/provide the claim of policyholders during hospitalization. It is important to keep an eye on the waiting period, required documents, and other aspects for filing health insurance claims easily and securely.

Naval Goel is the founder of He is an Associate Member of the Indian Institute of Insurance`, Pune. He has been authorized by IRDA to act as a Principal Officer of Insurance Web Aggregator.
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