First, obtain the insurer’s written reasons for rejecting the claim and the relevant policy clause. You can then use the insurer’s grievance process, Bima Bharosa, or, where eligible, the Insurance Ombudsman or another appropriate forum.
Policy exclusions, waiting periods, disclosures and hospital records can affect a claim. A cashless approval not being granted and the final rejection of a reimbursement claim may be different matters. A rejected claim does not by itself mean that the insurer is always at fault or that the policy is useless; it is important to check the reasons against the documents.
What should you do now?
- Compare the clause cited in the rejection letter with the policy wording.
- Send the insurer a reconsideration request, clarifying any missing documents or facts.
- If the response is unsatisfactory, consider making a further complaint after checking the claim type, limits and time limits.
Which documents should you keep?
The policy, proposal form, discharge summary, bills, claim papers and rejection letter.
Avoid this mistake
Concealing proceedings before different forums or changing your medical history may make the problem worse.
A hypothetical example
Cashless authorization was not granted at the hospital, but the policy is active. Ask the insurer to clarify whether this was a denial of the cashless request or a final rejection of the claim. Then separately check the reimbursement documents and policy conditions.
Does refusal of cashless treatment mean that no claim can be made?
Not necessarily. The possibility of reimbursement can be checked separately, subject to the policy terms.
Legal basis and useful sources
- IRDAI — Bima Bharosa grievance mechanism
- Consumer Protection Act, 2019 — complaints, unfair trade practices and remedies
This is general legal information. Advice may differ depending on your facts, applicable law and state rules.