Aditya Birla Health Insurance Claim Denied? How to Appeal

Aditya Birla Health Insurance (ABHI) has carved a distinctive niche in India's health insurance market through its Activ Health product range, which uniquely integrates wellness tracking and fitness benefits. Products like Activ Health Enhanced, Activ Health Platinum, and Activ Care are popular with health-conscious urban professionals — particularly in Bengaluru, Mumbai, and Delhi NCR — who are attracted by HealthReturns premium discounts and chronic condition coverage features.

Despite these innovative features, ABHI claim denials do happen, and the disputes often involve product-specific features like wellness benefits and chronic condition coverage that are unique to the Aditya Birla ecosystem.

Why Aditya Birla Health Insurance Denies Claims

Chronic condition coverage disputes: One of Activ Health's marquee features is coverage for pre-existing chronic conditions — like diabetes, hypertension, asthma, and hyperlipidemia — after a policy has been in force for 2 years. This is a lower waiting period than the standard 3–4 years. However, disputes arise over:

• Whether the 2-year period was correctly calculated
• Whether the specific chronic condition is on ABHI's covered list
• Whether the hospitalization is "directly related" to the chronic condition in the insurer's view

HealthReturns and wellness benefit disputes: Activ Health's HealthReturns program offers premium discounts based on fitness activity tracked through the app. Disputes occur when:

• The app records activity differently than the policyholder tracks it
• A step count or health score doesn't meet the threshold for the discount
• The premium reduction promised during sales doesn't materialize as expected

Specific disease waiting periods: Beyond the chronic condition coverage feature, Activ Health policies still have waiting periods for specific listed conditions. Claims within these windows are denied.

Non-medical expense deductions: Like other insurers, ABHI deducts items listed in its non-payable schedule. Some policyholders dispute deductions for items that were genuinely medically necessary.

Mental wellness claim disputes: Activ Health's mental wellness coverage is a selling point. But ABHI has had disputes over which mental health treatments are "covered" versus "excluded" — including some outpatient consultations and certain treatment modalities.

Day care and outpatient benefit limits: Some Activ Health plans include outpatient coverage with annual limits. Disputes arise when outpatient claims are rejected for exceeding annual sub-limits or for being classified incorrectly as inpatient versus outpatient.

Step 1: Grievance to Aditya Birla Health Insurance

Write to ABHI's Grievance Redressal Officer. ABHI is headquartered in Mumbai with offices in major cities. Their customer service is available through the Activ app, email, and written correspondence.

Include in your grievance:

• Policy number and claim reference
• The denial reason from the rejection communication
• Medical records and physician's certificate
• For chronic condition disputes: evidence of 2+ years of continuous policy and evidence of the condition being on the covered chronic condition list
• For wellness disputes: your HealthReturns activity records from the app

ABHI must respond within 15 working days.

Step 2: IGMS Portal and Bima Bharosa

File at policyholder.gov.in if ABHI's resolution is unsatisfactory. Call Bima Bharosa at 1800-4254-732. IRDAI's monitoring of IGMS complaints holds ABHI accountable for resolution timelines.

Step 3: Insurance Ombudsman

File with the Insurance Ombudsman in your jurisdiction.

• Disputes up to ₹50 lakh
• Free process
• Decision within 3 months
• Binding on Aditya Birla Health Insurance
• File within 1 year of final rejection

The Ombudsman applies IRDAI's standard regulations — not ABHI's proprietary wellness benefit terms — when evaluating disputes. This often works in policyholders' favor for disputes involving the application of general health insurance principles.

Step 4: Consumer Court

Consumer courts are available for disputes above ₹50 lakh or where you seek compensation for bad-faith denial or misrepresentation during the sales process.

Specific Strategies for ABHI Appeals

For chronic condition coverage disputes: Read your policy's chronic condition coverage rider carefully. The 2-year coverage kickin applies to specifically listed conditions. If your condition is on the list and the 2-year period has passed, the denial is challengeable.

For HealthReturns disputes: Export your step-count and health data from the Activ app. If there's a discrepancy between your records and ABHI's calculation, the app data is your evidence. ABHI's methodology for HealthReturns calculations should be disclosed in the policy terms.

For mental wellness denials: Cite the Mental Healthcare Act, 2017 and IRDAI's corresponding circular requiring parity coverage. Wellness-framed products like Activ Health that explicitly market mental wellness coverage cannot then deny claims on a narrow reading of "covered" mental health treatment.

For day care disputes: Reference the IRDAI standard day care procedure list. If your procedure is on that list, the denial is immediately challengeable.

Fight Back With ClaimBack

Aditya Birla Health Insurance's innovative products are marketed with promises of comprehensive coverage and wellness integration. When those promises don't materialize in claim settlement, IRDAI's framework is your recourse.

Start your appeal at ClaimBack — prepare a precise, evidence-based appeal that Aditya Birla must substantively address.

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal