What can I do if my health insurance claim is unfairly rejected?

Kevin

I was recently hospitalized for a surgery that was covered under my health insurance plan. However, after submitting the claim for reimbursement, the insurance company rejected it, stating that the treatment was “not medically necessary,” even though my doctor provided a detailed report justifying the procedure. The rejection has put me under severe financial stress, as the hospital bill was quite substantial.

How can I challenge this rejection and ensure that the insurance company honors my claim? What are my rights under the Insurance Act, and is there an ombudsman or regulatory body I can approach for faster resolution? Can I take legal action against the insurer for unfair practices, and what evidence will I need to support my case?

RajeshKumar

I understand how frustrating and stressful it must be to face a claim rejection, especially after following the necessary procedures and relying on your insurance for financial support. Here’s a step-by-step guide to help you challenge the insurance company’s decision and seek a fair resolution.

Review the Policy Terms and Gather Documentation
Start by thoroughly reviewing your health insurance policy document, especially sections related to "medically necessary treatments" and exclusions. Gather all documents related to your case, including the doctor’s report, hospital records, and any communication with the insurance company. Having this evidence organized will strengthen your claim.
Request a Written Explanation from the Insurance Company
Contact the insurance company and request a written, detailed explanation for the rejection. Insurance companies are required to provide clear reasons for claim denials. This explanation can help you identify if the company has overlooked any documentation or misunderstood the nature of your treatment.
File a Grievance with the Insurance Company
Most insurers have a grievance redressal mechanism. Submit a formal complaint to the company’s grievance cell, explaining your case and attaching all relevant documents, including the doctor’s justification. Be specific and clear in your request for a reassessment, citing any policy terms that support your claim.
Approach the Insurance Ombudsman
If your grievance remains unresolved or if the insurance company upholds its decision, you can file a complaint with the Insurance Ombudsman. The Ombudsman offers a free, impartial service to resolve disputes between policyholders and insurers. Submit your complaint online or in writing, attaching all documentation. The Ombudsman will review your case and may mediate or direct the insurer to reconsider your claim if the denial appears unjustified.
Consider Approaching the IRDAI (Insurance Regulatory and Development Authority of India)
The IRDAI regulates insurance companies and mandates fair treatment of policyholders. You can file a complaint with the IRDAI if you suspect unfair practices. While the IRDAI does not intervene in individual disputes, it does investigate broader issues and may pressure insurers to resolve cases ethically.
Prepare for Legal Action, if Necessary
If all other steps fail, consider filing a case in the Consumer Court under the Consumer Protection Act, 2019. Health insurance claims fall under consumer rights, and if the denial was unjustified, the court may order the insurer to pay the claim along with compensation for the financial and emotional distress caused. A consumer lawyer can guide you through the process and help prepare the necessary documentation, such as medical records, policy terms, rejection letters, and grievance reports.
Strengthen Your Evidence
Alongside the doctor’s report, obtain an affidavit or written statement from your doctor explaining the medical necessity of the treatment, if possible. Also, collect additional medical opinions if available, as multiple supporting documents can reinforce your case.
Stay Persistent and Follow Up
Throughout the process, maintain a record of all interactions, including dates, times, and the names of insurance representatives. Follow up regularly and document each step taken toward resolution, as this record can demonstrate your diligence and strengthen your position.

While this process can be time-consuming, staying proactive and gathering strong evidence can significantly improve your chances of a positive outcome. I hope this information helps, and I’m here to assist you if you need further guidance or representation. Remember, insurance companies are obligated to act fairly, and pursuing your rights can ensure justice in this matter.