Here is a list of steps to consider if your health insurance claim is rejected.
1. Do not let anger and emotions cloud your judgment. Take some time to read and re-read the claim repudiation letter. Find out which clause or condition of the policy it allegedly violates.
It is maybe possible that the insurer is justified in the rejection. Share necessary documents with a few intelligent associates/friends/relatives who can determine if it is worth challenging.
2. Once you are convinced with ample logic that your claim should be paid, contest the repudiation with the necessary details.
3. The insurer will probably stand by their rejection.
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4. Write to the insurance grievance cell stating you will complain to the ombudsman if you do not get a favourable reply. The result is likely to be the same. In some cases, the insurer may offer to play a small portion of the hospital bill, hoping that would appease us and we would not pursue the matter further.
If you are convinced (logically, not emotionally) that you deserve a bigger sum, you will not have to apply to the ombudsman online via https://cioins.co.in/Complaint/Online
Duties and functions of Insurance Ombudsman – an extract from the Ombudsman rule book.
The Ombudsman shall receive and consider complaints against an insurer (including
its agents and intermediaries) or an insurance broker on any of the following grounds:
(a) delay in settlement of claims beyond the time specified in the regulations, framed
under the Insurance Regulatory and Development Authority of India Act, 1999;
(b) any partial or total repudiation of claims by the life insurer, General insurer or the
health insurer;
(c) disputes over premiums paid or payable in terms of an insurance policy;
(d) misrepresentation of policy terms and conditions at any time in the policy document or policy contract;
(e) the legal construction of insurance policies in so far as the dispute relates to the claim;
(f) policy servicing related grievances against insurers and their agents and
intermediaries;
(g) issuance of life insurance policy, general insurance policy including health insurance
policy which is not in conformity with the proposal form submitted by the proposer;
(h) non-issuance of insurance policy after receipt of premium in life insurance and
general insurance, including health insurance;
5. You will need the following documents.
- All correspondence between you and the insurer with regard to the claim.
- KYC documents
- Insurance policy copy
6. You can file a complaint within one year of claim rejection or if the insurer has not responded for over a month. The complaint can be tracked via the above-linked website.
7. The Ombudsman may require you to come to their regional office for the hearing or may fix it online. You will need to be well prepared to handle any questions from the ombudsman or counter statements made by the insurer. It may be better to have legal representation or take the help of someone who can understand the legal language of the policy terms and conditions well.
Needless to say, all this will take time and effort. This is why it is important to read policy terms and conditions cover to over before buying the policy. Also, don’t forget these steps after buying a health insurance policy!
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