The insurer closed my health claim saying documents were missing. Is that allowed?
No. IRDAI's Master Circular on Protection of Policyholders' Interests, 2024 says: "No claim shall be rejected or closed for want of documents or for delayed intimation of claim" (para V.1(ii)).
The Health Master Circular goes further. The insurer and its TPA collect the documents from the hospital, and the policyholder shall not be required to submit them (para 17). A rejection that blames missing hospital papers is one the rules do not allow.
A claim you file yourself for reimbursement has to be settled within 15 days of submission, and a late settlement carries interest at bank rate plus 2% from the date of intimation. If the insurer needs something more, it can ask for it. Closing the file is not an option the rules give it.
To challenge it, complain to the insurer in writing. It has 14 days to resolve the complaint. If it rejects it, gives an answer you are unhappy with or stays silent for a month, the Insurance Ombudsman takes the complaint free of charge within one year, for awards up to ₹50 lakh, when the policy is personal or held by a sole proprietor or micro enterprise. The checker works out those dates for your claim.
If this is where you are
The insurer rejected my claim and quoted a clause. I need to answer it in writing before I can go to the ombudsman.
Appeal letter against a rejected insurance claim
A complaint letter to the insurer's grievance officer, with your policy clause and their reason set out, and a sheet with the dates that follow.
₹299₹499
Launch price until 30 November
Common questions
What should my complaint quote?
Para V.1(ii) of IRDAI's Master Circular on Protection of Policyholders' Interests, 2024, and para 17 of the Master Circular on Health Insurance Business. Ask the insurer to reopen the claim and decide it on its merits.
Can I complain online?
Yes. Bima Bharosa at bimabharosa.irdai.gov.in passes the complaint to the insurer and to IRDAI. It is the only official address for it.
Want this handled for you? Tell us where you stand and we prepare the papers and take you through the filing.