A clear escalation path including insurer, TPA, Ombudsman, and legal options.
Filing a health insurance claim can be stressful, especially during a medical emergency.
Sometimes insurers delay or even deny claims due to missing documents,
incomplete paperwork, or policy-related issues. The good news is that many of these problems can be fixed
with the right steps.
1. Understand Why Your Claim Was Delayed
A delay does not always mean rejection. Common reasons include:
- Missing medical reports
- Incomplete claim form
- Waiting period not completed
- Pre-authorization delay (cashless)
- Additional investigation required
- Incorrect hospital documents
- Delay in informing the insurer
What to do: Contact your insurer/TPA, ask for the exact reason,
submit missing documents, and follow up regularly.
2. Review the Reason for Claim Denial
If your claim was denied, the insurer must give a written explanation. Common reasons for denial include:
- Non-disclosure of pre-existing conditions
- Treatment not covered under the policy
- Claim filed after the deadline
- Incomplete or incorrect documents
- Policy exclusions (cosmetic, dental, infertility, etc.)
- Room rent limit exceeded
What to do: Read the denial letter carefully and compare it with your policy terms.
3. Collect All Relevant Documents
Gather these documents before proceeding with an appeal:
- Policy document
- Hospital bills and receipts
- Doctor’s notes and reports
- Discharge summary
- Diagnostic reports
- Rejection letter
- All communication with insurer/TPA
4. Ask the Hospital for Clarifications
Hospitals may sometimes make errors like:
- Incorrect diagnosis codes
- Missing treatment notes
- Wrong discharge summary
What to do: Visit the hospital’s insurance desk and request corrected or updated documents.
Ask the doctor for a medical justification if needed.
5. File a Claim Appeal
If you believe your claim was wrongly denied, file a reconsideration request.
- Write a claim reconsideration letter
- Attach missing or corrected documents
- Submit to the insurer or TPA
- Follow up regularly and keep records
Most insurers reconsider claims when proper justification is provided.
6. Escalate to Higher Authorities
If the insurer is not responding, escalate the issue.
Level 1: Grievance Redressal Officer (GRO)
Email or call the GRO of your insurer.
Level 2: IRDAI (IGMS Portal)
Submit your complaint through the official IRDAI grievance system.
Level 3: Insurance Ombudsman
If still unresolved, file a complaint with the Insurance Ombudsman.
7. Keep All Communication Records
Always save emails, SMS updates, call logs, receipts, and documents. These help during escalations
or appeals.
8. Prevent Future Claim Issues
To avoid delays or denials in the future:
- Disclose medical history honestly
- Check your room rent limit
- Inform the insurer on time
- Use network hospitals for cashless claims
- Organize your medical documents properly
- Understand waiting periods clearly
Conclusion
A delayed or denied claim is frustrating, but it’s not the end. With proper documentation, follow-up,
and escalation, most claims can be resolved. Stay calm, collect all required documents, and challenge
the decision in a systematic way.
