Health Insurance Claim Denied in India: IRDAI Grievance Process Guide

Health Insurance Claim Denied in India: Know Your Rights and How to Fight Back

India's health insurance market has grown dramatically over the last decade, but so has the number of claim disputes. Whether your claim involves a cashless hospitalization denial, a reimbursement rejection, or a pre-authorization dispute, Indian policyholders have strong regulatory protections under the Insurance Regulatory and Development Authority of India (IRDAI).

This guide covers the complete grievance process — from filing with your insurer to escalating to the Insurance Ombudsman (Bima Lokpal) — and gives you the specific steps and timelines you need to know.

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India's Insurance Regulatory Framework

IRDAI (Insurance Regulatory and Development Authority of India)

IRDAI is the apex regulatory authority for the insurance sector in India, established under the IRDAI Act 1999. IRDAI:

• Licenses and regulates all insurance companies in India
• Sets consumer protection standards and claim handling rules
• Operates an integrated complaints portal (IGMS)
• Has the power to direct insurers to pay claims and impose penalties

Insurance Ombudsman (Bima Lokpal)

The Insurance Ombudsman, now formally known as Bima Lokpal, is a free, independent dispute resolution mechanism established under the Redressal of Public Grievances Rules 1998 (revised in 2017). There are 17 Bima Lokpal offices across India, covering different geographic areas.

Bima Lokpal can:

• Award compensation up to ₹30 lakh (approximately USD 36,000)
• Issue binding decisions on insurers
• Provide resolution within 3 months of receiving a complete complaint

This is one of the most consumer-friendly systems in the world for insurance disputes — and it is completely free.

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Why Health Insurance Claims Are Denied in India

Common reasons for health insurance claim denials in India:

• Pre-existing conditions: Conditions that existed before the policy was issued, during the waiting period (typically 2–4 years)
• Non-disclosure: The proposer did not declare relevant health information at the time of policy issuance
• Waiting periods: Disease-specific waiting periods (e.g., many policies exclude certain conditions for the first 1–2 years)
• Policy exclusions: Specific treatments or conditions excluded by the policy
• Procedural grounds: Claim not filed within the prescribed time limit, treatment at a non-empanelled hospital
• Cashless pre-authorization denied: The Third-Party Administrator (TPA) or insurer declined to authorize cashless treatment

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Step 1: Obtain the Denial in Writing From Your Insurer

Immediately request a written rejection letter from your insurance company or TPA that:

• Clearly states the reason for rejection
• Cites the specific policy clause or section relied upon
• Provides your claim reference number

Under IRDAI's Protection of Policyholders' Interests Regulations 2017, insurers must provide written reasons for claim rejections. If you received only a verbal denial, put your request for written rejection in writing immediately.

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Step 2: File a Formal Grievance With Your Insurance Company

Under IRDAI regulations, every insurer must have a Grievance Redressal Officer (GRO) and a formal grievance process. The insurer must:

• Acknowledge your grievance within 3 working days
• Resolve the grievance within 15 working days

How to file:

• Contact the insurer's Grievance Redressal Officer (find their contact on the insurer's website — all insurers are required to publish this)
• File in writing by email to the GRO or through the insurer's official portal
• Include all claim documents, the rejection letter, and your grounds for dispute

Keep a copy of everything you submit.

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Step 3: Escalate to IRDAI via IGMS (If Unresolved in 15 Days)

If the insurer does not resolve your complaint within 15 working days, or if the resolution is unsatisfactory, escalate to IRDAI through the Integrated Grievance Management System (IGMS).

IGMS Portal:

• Website: igms.irda.gov.in
• IRDAI Call Centre: 155255 (Bima Bharosa) — toll-free from any landline or mobile
• Email: complaints@irdai.gov.in

What to submit on IGMS:

• Your personal details and policy number
• Insurer name and the claim reference number
• Nature of the grievance
• Copy of the rejection letter
• Copy of your GRO complaint and the insurer's response (or evidence of non-response)
• Supporting medical documents

IRDAI will register your complaint and take it up with the insurer directly. Insurers are required to respond to IRDAI grievance references promptly.

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Step 4: File With Bima Lokpal (Insurance Ombudsman)

If IGMS escalation does not produce a satisfactory outcome, or if you have already exhausted the insurer's internal process, file a complaint with the Bima Lokpal (Insurance Ombudsman).

Eligibility:

• The dispute involves a personal lines insurance policy (health, life, motor, travel, home)
• The claim value is up to ₹30 lakh
• You have filed with the insurer first (and received a rejection or no response within 30 days)

How to file:

• Online: Bima Bharosa portal — register.ombudsman.gov.in
• In person or by post: Find your local Bima Lokpal office at gbic.co.in/ombudsman.html
• No fee: The process is entirely free

Documents required:

• Policy document
• Claim rejection letter
• GRO complaint and response
• Medical records, hospital bills, discharge summaries
• Identity proof (Aadhaar, PAN)

Timeline: Bima Lokpal must resolve complaints within 3 months of receiving all complete documentation.

Bima Lokpal offices include: Mumbai, Delhi, Kolkata, Chennai, Hyderabad, Bengaluru, Pune, Ahmedabad, Chandigarh, Lucknow, Bhopal, Bhubaneswar, Guwahati, Jaipur, Kochi, Noida, and Patna.

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Step 5: Consumer Forum and Court Options

Beyond Bima Lokpal, you can file with:

• District Consumer Disputes Redressal Commission: For disputes involving deficiency in service. Can award compensation beyond the insurance claim amount.
• State and National Consumer Commissions: For higher-value disputes
• Civil Court: For complex legal disputes or disputes above Bima Lokpal's ₹30 lakh limit

The Consumer Protection Act 2019 expanded consumer protections and allows online complaint filing through the National Consumer Helpline (1800-11-4000 or 14404).

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Cashless vs. Reimbursement Claims: Different Strategies

Cashless Claim Denial

If your cashless pre-authorization was denied:

1. Ask the hospital's TPA desk to initiate an escalation to the TPA supervisor or insurer immediately
2. Proceed with treatment and keep all original bills — you can claim reimbursement
3. File a formal complaint about the cashless denial with both the insurer and IRDAI
4. IRDAI takes cashless denial complaints seriously, particularly for emergency treatments

Reimbursement Claim Denial

If you paid out of pocket and the reimbursement was denied:

1. Ensure you have all original bills, receipts, discharge summary, and doctor prescriptions
2. File the GRO complaint with all original documents
3. If TPA-related delay is involved, file directly with both the TPA and the insurer (both are accountable under IRDAI rules)

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Special Protections: IRDAI's Recent Reforms

IRDAI has significantly strengthened consumer protections in recent years:

• No claim rejection after 8 years: Under the Master Circular on Health Insurance (2023), if a policyholder has held a health policy for 8 years without a claim on the specific condition, the insurer cannot reject claims on grounds of non-disclosure or misrepresentation after that period.
• Standardized health insurance products: IRDAI introduced standardized products (Arogya Sanjeevani) with defined, transparent terms.
• Cashless claim resolution within 1 hour: IRDAI has directed insurers to process cashless pre-authorization within 1 hour for planned procedures and within 3 hours for emergency admissions.

If your insurer violated these specific timelines or the 8-year non-rejection rule, cite this explicitly in your IGMS complaint.

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Common Mistakes in India Insurance Appeals

1. Not filing with the GRO before going to IGMS or Bima Lokpal. The Ombudsman requires you to have filed with the insurer first. Skip this step and your Bima Lokpal complaint may be returned.

2. Missing the Bima Lokpal filing deadline. You must file within 1 year of the insurer's final rejection. Don't delay.

3. Submitting photocopies without attestation. Bima Lokpal typically requires self-attested copies of documents.

4. Not understanding the waiting period provisions. Many claim denials involve waiting periods that policyholders weren't aware of. Read Section 4 ("Exclusions and Waiting Periods") of your policy carefully.

5. Not appealing cashless denials. Many people accept a cashless denial, pay out of pocket, and then fail to file a formal reimbursement claim and grievance. You are entitled to both reimbursement and a regulatory complaint about the cashless denial.

6. Not citing IRDAI regulations. Mentioning IRDAI's Protection of Policyholders' Interests Regulations 2017 and specific IRDAI circulars in your complaint signals regulatory awareness and is taken more seriously.

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Writing Your Appeal Letter

Your grievance should cite the relevant IRDAI regulations, specifically name the GRO you are writing to, and attach all supporting documentation. ClaimBack can generate a structured, regulation-citing appeal letter for Indian health insurance denials that includes the right regulatory language and is formatted for the GRO complaint process. Visit claimback.app to create your letter.

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Summary: India Health Insurance Appeal The Full Fight

1. Request the written rejection with specific policy clause citations from your insurer or TPA
2. File with the Grievance Redressal Officer (GRO) — insurer must respond within 15 working days
3. Escalate to IRDAI via IGMS (igms.irda.gov.in) if unresolved — call Bima Bharosa (155255)
4. File with Bima Lokpal for free, independent adjudication on claims up to ₹30 lakh
5. File with the Consumer Forum for additional compensation for deficiency of service
6. Act within 1 year of the final rejection to preserve your Bima Lokpal rights