What to do if your health insurance claim is rejected

Don't panic — read the letter carefully

A repudiation letter must state the reason and the specific policy clause relied on. Find both. The reason is the thing you'll respond to; the clause is where you check whether the insurer applied it correctly.

Test the reason against your own policy

Most rejections cite an exclusion or condition — a waiting period, a pre-existing disease, non-disclosure, or a documentation gap. Open your policy wording to that clause and read exactly what it requires. Insurers sometimes apply a clause more broadly than its wording allows.

Gather evidence that speaks to the reason

Generic documents rarely help. Match your evidence to the stated reason: if the reason is a pre-existing disease, a treating doctor's certificate of the first-diagnosis date is far more useful than another copy of the bill.

Respond with a formal, factual representation

Write to the grievance cell. State the facts, reference the clause and page, and ask — in writing — for the specific basis of their conclusion. Keep it calm and firm; you are building a record, not winning an argument by email.

Escalate only after you've given them a chance

If the response is unsatisfactory, the path runs through the insurer's grievance officer, then IRDAI's Bima Bharosa platform, then the Insurance Ombudsman. Keep proof of every submission.

Upload your policy and the insurer’s letter — Claim Saathi reads both, finds the exact clause, and helps you respond.