My claim was rejected under an exclusion. How do I check whether it applies?
IRDAI's rule is plain: "Insurers shall mandatorily include in the policy document all the applicable exclusions for a particular product." No further deduction may be made from a claim in the name of any other exclusion (Master Circular on Protection of Policyholders' Interests, Chapter IV para 16.3). It covers life, health and general policies.
The Customer Information Sheet you got at purchase has to summarise the exclusions as well. For health, we found no IRDAI-wide standard list of exclusions in force today; the 2020 list sat in a circular IRDAI has since withdrawn. Your policy's own list decides.
Read the clause the rejection letter cites against your policy document. The letter has to cite one (Health Master Circular, para 17). If the clause is not in your policy, or does not cover what happened, the rejection is open to challenge.
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
Can an exclusion be added after I bought the policy?
The rule ties exclusions to the policy document for the product. A claim cannot be cut under an exclusion that is not in it.
Does the 60-month moratorium remove exclusions?
No. The moratorium stops challenges for non-disclosure or misrepresentation after 60 months. The policy's exclusions still apply.
Want this handled for you? Tell us where you stand and we prepare the papers and take you through the filing.