Health claim rejected as not medically necessary

IRDAI's current health rules carry no standard definition of medically necessary, day care or domiciliary hospitalisation that binds every policy. The 2020 standard definitions sat in a circular the Health Master Circular has withdrawn (Annexure 6). Your policy's own definitions decide the question.

Insurers must offer products that cover domiciliary hospitalisation, outpatient care, day care and home care. That duty is about what is on sale; it does not mean your policy covers them. AYUSH treatment is defined in the regulations, and each insurer needs a board policy that treats it at par with other treatment.

Every policy shares the process. A claim cannot be repudiated without the approval of the insurer's committee, and the letter must cite the specific policy term (Health Master Circular, para 17). Ask for the medical opinion the insurer relied on and set your treating doctor's reasons for admission against 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.