Guidance For Free

Writing a formal complaint and escalating step by step

Health Insurance Claim Rejected? How to Escalate in India

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by

sulinder555
in

If your health insurance claim was rejected, or only part of it was paid, you do not have to accept it. There is a free, official ladder you can climb. First the insurer’s own grievance cell. Then IRDAI through Bima Bharosa. Then the Insurance Ombudsman. None of these steps needs a lawyer or any fee.

Before you start

  • Policy copy (or e-card) and policy number.
  • Claim number and the rejection or part-payment letter (often called a repudiation letter). Note the exact reason given.
  • Hospital papers: discharge summary, final bill, reports, prescriptions and payment receipts.
  • Any emails, SMS or letters between you and the insurer or TPA.
  • An ID proof (Aadhaar, passport, driving licence) and a recent photo, needed for the Ombudsman’s online form.
  • A simple timeline on one page: admission date, discharge date, claim date, rejection date.

Keep scanned copies (PDF or clear photos) in one folder. You will upload the same papers more than once.

Step 1: Complain in writing to the insurer’s grievance cell

  1. Read the rejection reason carefully. Find the matching clause in your policy wording. Note whether you think it was applied wrongly.
  2. Write to the insurer’s Grievance Redressal Officer (GRO). IRDAI publishes GRO email IDs of all insurers on its How to make a complaint page. You can also walk into any branch.
  3. Attach the rejection letter and supporting documents. Ask for the claim to be reviewed and paid.
  4. Get a written acknowledgement with a date or a complaint number. Save the email.
  5. Wait. IRDAI says the insurer should resolve your complaint not later than two weeks (14 days) from receipt.

Step 2: Escalate to IRDAI through Bima Bharosa

If there is no reply in two weeks, or you are not happy with the reply, escalate to IRDAI’s Grievance Redressal Cell.

  1. Go to https://bimabharosa.irdai.gov.in/, create a profile and click Register Complaint. You get a token number by email/SMS. Use it to track the complaint.
  2. Or email [email protected] with your complaint and attachments.
  3. Or call the toll-free IRDAI Grievance Call Centre: 155255 or 1800 4254 732 (8 AM to 8 PM, Monday to Saturday, as per IRDAI).
  4. Mention your earlier complaint number with the insurer and its date.

Important: IRDAI asks the insurer to re-examine your complaint. It does not decide the claim amount like a court. If you are still not satisfied, go to the Ombudsman. IRDAI only accepts complaints from the insured or the claimant, not from agents, advocates or other third parties.

Step 3: Approach the Insurance Ombudsman

The Insurance Ombudsman can decide disputes about full or partial claim rejection and delays. It is free, and you do not need a lawyer.

Who can go and when

  • You must have complained to the insurer first.
  • The insurer did not reply within one month, or you are not satisfied with its reply.
  • You must file within one year from the date of the insurer’s rejection, or from the end of one month after your complaint if the insurer did not reply.
  • The amount of compensation sought should not exceed Rs 50 lakh.
  • The same matter must not be pending in, or already decided by, a court, consumer forum or arbitrator.

How to file

  1. Open the online complaint form on the Council for Insurance Ombudsmen (CIO) website. You can also email or post a signed complaint, or walk in to an Ombudsman office.
  2. Choose the office covering your home address or the insurer’s branch that issued the policy. See the list of Ombudsman offices.
  3. Upload: your complaint to the insurer, the insurer’s rejection letter, policy copy, KYC proof, a photo (for online filing) and other papers.
  4. Write the amount you are claiming and why the rejection is wrong, clause by clause.
  5. Save the complaint number and track it at Track Complaint.

The Ombudsman may hold a hearing in person or by video. If both sides agree to mediation, a recommendation comes within one month of that consent. Otherwise, an award is passed within three months of receiving all requirements from you. The award binds the insurer. If you disagree with it, you can still take the normal legal route.

Sample complaint letter

To: The Grievance Redressal Officer, [Insurer name]
Subject: Review of rejected claim no. [___], policy no. [___]

I am the policyholder/insured under the above policy. I was admitted to [hospital] from [date] to [date] for [condition]. My claim of Rs [amount] was rejected/partly paid on [date] citing [reason quoted from letter].
This rejection is not correct because [short reason, e.g. the condition is not excluded under clause __ / the waiting period was completed on __ / all documents were submitted on __].
I request you to review the claim and pay Rs [amount] within the time allowed under IRDAI rules. Copies of the rejection letter, policy, discharge summary and bills are attached.

Name, phone, email, address, date

Use the same letter, updated with your earlier complaint number, for Bima Bharosa and the Ombudsman.

Common mistakes

  • Going to IRDAI or the Ombudsman before writing to the insurer. Always complain to the insurer first.
  • Missing the one-year limit for the Ombudsman. Note the rejection date and set a reminder.
  • Not keeping proof that you complained (acknowledgement, email, complaint number).
  • Writing an emotional letter with no facts. Quote the rejection reason and the policy clause.
  • Leaving out the rejection letter or policy copy. Incomplete complaints get delayed.
  • Paying an agent or a website to “fast-track” the claim. Bima Bharosa and the Ombudsman never charge fees. Do not scan QR codes or share OTPs with callers who promise refunds.
  • Filing at a consumer court and the Ombudsman for the same issue. The Ombudsman cannot take a matter already before a court or consumer forum.

Official links

This guide is general information, not legal advice. Rules can change, so check the official pages before you file.

Last checked: November 2026

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