Care Health Insurance Claim Denied? Here's How to Appeal

Care Health Insurance Company Limited — formerly known as Religare Health Insurance — is one of India's leading standalone health insurers, with a product range including Care (formerly Religare Care), Care Freedom for pre-existing conditions, Care Senior for senior citizens, Care Advantage, and various top-up plans. Care Health markets itself on the promise of cashless treatment across an extensive hospital network and straightforward claim processing. Despite this positioning, policyholders regularly receive claim denials — and many are unaware that these denials can be formally challenged through India's insurance regulatory system, free of charge, and with binding outcomes at the Ombudsman level.

Why Care Health Insurance Denies Claims

Care Health denials follow predictable patterns that are important to understand before filing an appeal:

• Pre-existing disease (PED) waiting period exclusions — Care Health policies impose waiting periods for pre-existing diseases, typically 2 to 4 years depending on the specific product. Care Freedom has a modified structure for pre-existing conditions. If denied on PED grounds, examine whether the insurer has established a clear causal link between your current hospitalization and the alleged pre-existing condition — if that link is debatable, you have a basis for challenge.
• Specific disease waiting periods — Beyond PED exclusions, Care Health policies include 1 to 2-year waiting periods for specific listed conditions: hernia, cataracts, joint disorders, varicose veins, and others. Denials based on these waiting periods require confirming whether the specific condition is listed and whether the waiting period has actually been served.
• Cashless denial at the pre-authorization stage — Hospitals apply for cashless authorization before treatment begins. Care Health's pre-authorization team may deny authorization citing documentation gaps, unverified hospitalization necessity, or sub-limit applicability. These pre-authorization denials can be escalated immediately.
• "Not medically necessary" for the procedure or hospitalization — Care Health may determine that the hospitalization or procedure was not medically required based on its internal clinical criteria, even when the treating physician has documented clinical necessity.
• Policy sub-limits and room rent restrictions — Care Health policies include sub-limits on specific procedures (e.g., cataract surgery, hernia repair) and room rent limits that, when exceeded, trigger proportional claim reductions or partial denials. These are contractual but should be reviewed against the policy schedule.
• Non-disclosure or misrepresentation at inception — Care Health may invoke non-disclosure of pre-existing conditions at the time of purchase to deny claims, particularly where the policyholder had prior medical consultations not disclosed in the proposal form.

How to Appeal

Step 1: Read the Denial Letter and Identify the Specific Policy Clause

Care Health must provide a written denial stating the specific policy clause or exclusion relied upon. Under IRDAI (Protection of Policyholders' Interests) Regulations 2017, vague denials are non-compliant. If the denial reason does not cite a specific clause, request written clarification citing the exact provision. Under IRDAI regulations, Care Health must settle or reject a claim within 30 days of receiving all required documents — delays beyond this are separately challengeable.

Step 2: Gather Your Full Documentation Package

Collect the complete Care Health policy document and schedule with all endorsements, the denial letter with the specific clause cited, the original claim form and hospital bills, discharge summary, indoor case papers, laboratory reports and investigation results, the treating physician's certificate and prescriptions, and all prior correspondence with Care Health dated chronologically. For PED disputes: collect records showing the treatment history and supporting the argument that the current condition is not causally related to any pre-existing condition.

Step 3: File a Formal Complaint with Care Health's Grievance Redressal Officer

All IRDAI-regulated insurers must maintain a dedicated Grievance Redressal Officer. File a formal written complaint with Care Health's Grievance Cell, citing the specific denial reason, the policy clause you believe covers the claim, and the factual basis for your claim. Request a written response with a grievance reference number. Care Health must resolve your complaint within 15 days under IRDAI guidelines.

Step 4: Escalate to the IRDAI Bima Bharosa Portal

If Care Health does not resolve your complaint within 15 days or provides an unsatisfactory response, escalate to IRDAI's integrated grievance redressal platform at bimabharosa.irdai.gov.in. You can also call the IRDAI consumer helpline at 155255 (toll-free) or 1800 4254 732. The portal tracks your complaint and prompts a regulated response from Care Health within IRDAI's prescribed timeframe.

Step 5: File with the Insurance Ombudsman for Your Region

For disputes up to Rs. 50 lakh, file a complaint with the Insurance Ombudsman (Bima Lok Pal) for your region under the Insurance Ombudsman Rules 2017. The Ombudsman process is free, typically faster than civil litigation, and can result in a binding award compelling Care Health to pay. File within one year of Care Health's final rejection. Locate your regional Ombudsman through the IRDAI website at irdai.gov.in.

Step 6: Consumer Forum for Larger Disputes or Persistent Non-compliance

For disputes exceeding Ombudsman jurisdiction or where regulatory channels have not resolved the matter, file a complaint under the Consumer Protection Act 2019 with the appropriate State Consumer Forum (for claims up to Rs. 1 crore) or the National Consumer Disputes Redressal Commission (NCDRC) for higher-value claims. Document every step of the regulatory process — this record strengthens your consumer court complaint.

What to Include in Your Appeal

• Care Health policy document and schedule with all endorsements, highlighting the coverage provisions applicable to your claim
• Denial letter with the specific policy clause cited by Care Health
• Complete hospital records: discharge summary, indoor case papers, investigation reports, and itemized bills
• Treating physician's certificate and prescriptions clearly establishing medical necessity
• Care Health Grievance Cell complaint acknowledgment and reference number
• IRDAI Bima Bharosa complaint reference number if escalated to the portal

Fight Back With ClaimBack

IRDAI regulations and India's free Insurance Ombudsman process give Care Health policyholders genuine, accessible tools to challenge unfair denials — from the insurer's internal grievance cell to a binding Ombudsman award issued at no cost to the policyholder. A clear, well-documented complaint letter citing the specific policy provision and IRDAI framework significantly improves your outcome at each stage. ClaimBack generates a professional appeal letter in 3 minutes, tailored to your Care Health denial.

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