1. Identify the Exact Ground for Claim Rejection
Insurers are legally mandated to issue a formal written Repudiation Letter clearly citing the specific policy clause or exclusion used. Common reasons include:
- Alleged non-disclosure of Pre-Existing Disease (PED).
- Treatment taken within the initial 30-day or specific-illness waiting period.
- Hospitalization not meeting the 24-hour minimum criterion (where day-care was not specified).
- Discrepancy in medical records, date of diagnosis, or physician statements.
2. Step 1: File Formal Representation with the Insurer Grievance Cell (GRO)
Write a detailed representation letter addressed to the Grievance Redressal Officer (GRO) of the insurance company:
- Attach supporting doctor certificates clarifying that the ailment was not pre-existing or that admission was medically necessary.
- Quote the relevant IRDAI Master Circular provisions.
- The insurer must respond with an official resolution within 14 days.
3. Step 2: Escalate to IRDAI Bima Bharosa (IGMS)
If the insurer does not respond within 14 days or rejects your review, lodge a complaint on the official IRDAI portal:
IRDAI Bima Bharosa Portal: bimabharosa.irdai.gov.in | Toll Free: 155255 / 1800 4254 732
4. Step 3: Approach the Insurance Ombudsman (Free Judicial Redressal)
The Insurance Ombudsman is a quasi-judicial body set up by the Government of India to resolve disputes up to ₹50 Lakhs.
- Zero cost to policyholders — no advocate or court fee required.
- Ombudsman rulings are legally binding on the insurance company.