What If My Health Insurance Claim Is Rejected?

5 min read | Updated on June 16, 2025, 16:04 IST

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Upstox is a leading Indian financial services company that offers online trading and investment services in stocks, commodities, currencies, mutual funds, and more. Founded in 2009 and headquartered in Mumbai, Upstox is backed by prominent investors including Ratan Tata, Tiger Global, and Kalaari Capital. It operates under RKSV Securities and is registered with SEBI, NSE, BSE, and other regulatory bodies, ensuring secure and compliant trading experiences.

A week before Diwali, Mohit’s 1.5-year-old son was diagnosed with dengue. He had to be hospitalised as the platelet counts were too low. The parents were quick to respond and chose a nearby hospital for fast treatment. The child was discharged after three days and had fully recovered. The treatment cost Mohit ₹35000, but he was not worried as he had comprehensive health insurance coverage.

However, during the discharge, the TPA informed him that the insurance company rejected the claim, citing that there was no need for hospitalisation in the given case, as the child responded to medicines from the first day of diagnosis. However, when Mohit called the helpline, he was asked for a letter from the attending doctor citing the importance of hospitalisation, and the claim was swiftly processed. Mohit cannot forget how furious he was for those few minutes, when despite paying insurance premiums for years, his claim was rejected.

There might be different circumstances when your health insurance claim might be rejected. In a few cases, the rejection could be justified, but in many cases, such rejection is unacceptable for a policyholder. When you or someone from your family is going through hospitalisation and treatment, the last thing you want is an additional financial stress due to claim rejection.

However, if you are vigilant, know your policy, and understand your rights, there are proper channels and ways through which you can appeal against such rejections and avoid such situations in the future.

Common Reasons for Health Insurance Claim Rejection

Let us first understand which are the most common reasons why a health insurance claim might be rejected:

Incomplete Documentation

Missing medical reports, incorrect claim forms, or the absence of original bills can lead to outright rejection. For instance, your claim can be delayed or rejected if one or more receipts are missing.

Policy Exclusions

Treatments or conditions not covered under your policy, like cosmetic surgery or certain pre-existing ailments within the waiting period, are common traps.

Delayed Intimation

Informing the insurer too late about hospitalisation may violate the terms. For planned and unplanned hospital visits, informing the insurer as soon as possible is important. Do check your policy for the specific deadlines (generally between 24 and 48 hours of admission).

Lapsed Policy

Even a short lapse in premium payment can void your coverage.

Wrong Hospital or Treatment Type

Non-network hospital visits under a cashless claim or unapproved treatments can disqualify claims.

Non-Disclosure of Medical History

Suppressing pre-existing conditions or lifestyle habits like smoking can result in claim denial.

Immediate Steps To Take After Claim Rejection

The first and most important thing is not to panic. There might be different reasons for such rejection, and you must first ask for a written explanation from the insurance company. Review your policy to check if the treatment is covered under another clause. If it’s a documentation issue, submit the missing paperwork quickly. Hospitals often assist with resubmissions. However, do not wait too long to submit different documents (as required), as it will help in enhancing the chances of reversing the rejection decision.

The Claim Appeal Process: Filing a Dispute

If you feel that the rejection was unjustified and your insurance company should have covered the specified disease and treatment, you can file a claim against the rejection. First, it is important to evaluate the reason for rejection cited by the insurer. You must ensure that all documentation is proper and that there are no missing documents.

In addition, you can file a dispute or appeal by following these steps:
Submit a written complaint with supporting documents and a clear explanation to your insurance company.
Ensure your claim form, hospital records, and medical bills are complete and match policy terms.
If unresolved, contact the insurance company's Grievance Redressal Officer (GRO).
You can also contact the Insurance Ombudsman for claims under ₹30 lakhs without legal fees. In addition, there is a legal route to the consumer forum, but you might require a lawyer, and the entire process is a bit more time-consuming.
Insurers generally respond to the appeals within 15 days. You should always document all the communications.

Tips to Prevent Future Claim Rejections

Here are a few things you should do to prevent any future claim rejections:

Always disclose any existing issues or diseases in writing. If the insurer agrees to waive the waiting period, ask for a document suggesting such a waiver.
Always maintain proper documentation, as any missing bill can easily lead to a claim rejection.
You should know your policy well, especially the inclusions and exclusions part.
Try to choose the network hospitals for a cashless and swift procedure.
Always inform the insurer about hospitalization as soon as you can.

Summing Up

Health insurance claim rejections can be quite stressful. For anyone facing hospitalisation of their loved one, another financial strain is the last thing to expect. However, claim rejections can be tackled with a proper strategy. With the right knowledge and swift action, many rejections can be appealed or resolved. More importantly, being proactive from understanding your policy to maintaining proper documentation can help prevent such setbacks.

FAQs

What should I do if my health insurance claim is rejected?

Contact your insurer, understand the reason, and start the appeal process.

Can I challenge a rejected claim?

Yes, through the insurer’s grievance cell, Ombudsman, or Consumer Forum.

How can I avoid future claim rejections?

Disclose your health history, understand your policy, and submit complete documents.

Is there a time limit to appeal a rejected health insurance claim?

Yes, most insurers allow appeals within 30 to 90 days of rejection. Always check your policy terms or contact customer support for the exact timeframe.

Can I get external help to appeal a rejected claim?

Yes, in addition to contacting the Ombudsman, you can also seek help from IRDAI’s grievance redressal portal or consult a legal advisor if needed.

About Author

Upstox Desk

Team of expert writers dedicated to providing insightful and comprehensive coverage on stock markets, economic trends, commodities, business developments, and personal finance. With a passion for delivering valuable information, the team strives to keep readers informed about the latest trends and developments in the financial world.