Health Insurance Claim Denied in Pakistan: Guide

Pakistan's health insurance landscape is evolving rapidly, with government health programs expanding alongside a growing private insurance sector. Whether your denied claim is from a private insurer regulated by SECP, a government-backed scheme like Sehat Sahulat, or a state-owned entity like State Life Insurance, you have rights — and a process to exercise them.

Pakistan's Health Insurance Ecosystem

Private health insurance. The Securities and Exchange Commission of Pakistan (SECP) regulates private insurance companies. Major health insurers include Jubilee Life Insurance, EFU Life Assurance, Adamjee Insurance, UBL Insurers, and Allianz EFU. Most private health insurance in Pakistan is employer-provided group coverage; individual health insurance is less common but growing.

Government health programs.

• Sehat Sahulat Programme: A government-funded health insurance program operating in Punjab, Khyber Pakhtunkhwa (KP), and Sindh. It provides cashless treatment at empanelled hospitals for a defined benefit package.
• Sehat Card: Issued to enrolled Sehat Sahulat beneficiaries as the access tool for cashless treatment.
• Prime Minister's Health Programme (at federal level).

State Life Insurance Corporation (SLIC). The government-owned life insurer, regulated separately. Offers life insurance with health riders and group health coverage.

Why Health Insurance Claims Are Denied in Pakistan

Pre-existing condition exclusions. This is the most common denial reason. Private insurers routinely exclude conditions that existed before coverage began, often for 1–2 years from the policy start date, or permanently if declared at underwriting.

Non-empanelled hospital (Sehat Sahulat). Government programs only cover treatment at empanelled (approved) hospitals. If you sought treatment at a hospital not on the approved list, cashless coverage will not apply.

Documentation deficiencies. Pakistan's insurance claims process is highly documentation-dependent. Common gaps: missing hospital admission forms, incomplete doctor reports, absent laboratory results, lack of proper referrals. Any gap can delay or trigger a denial.

Coverage limit exhausted. Many group policies have annual benefit limits. Once the limit is reached, further claims are denied.

Non-covered treatment. Certain procedures — cosmetic surgery, dental, optical, fertility treatment, and experimental procedures — are typically excluded from health policies.

Policy lapse. If premium payments were missed and the policy lapsed, any claims during the lapse period will be denied. The reinstatement process, if available, may impose new waiting periods.

Coordination of benefits. If an employee has coverage under both a spouse's and their own employer's group plan, the coordination of benefits rules must be followed. Claims to a secondary insurer require the primary insurer's EOB)" class="auto-link">explanation of benefits first.

Your Rights Under SECP Regulation

All private insurers operating in Pakistan must comply with the Insurance Ordinance, 2000 and SECP's regulatory framework. SECP's Insurance Division oversees market conduct, policyholder protection, and complaint handling.

Key policyholder rights:

• The right to receive a written denial with reasons
• The right to internal appeal
• The right to SECP complaint
• The right to Federal Ombudsman (Mohtasib) complaint

Step-by-Step Appeal Process

Step 1: Request a Written Denial Letter

If your claim was denied verbally or by SMS, formally request a written denial letter stating the specific policy clause and factual basis for the denial.

Step 2: Internal Complaint to the Insurer

Submit a formal written complaint to the insurer's customer services or complaints department. Include:

• Your policy number and claim reference
• The denial reason as stated
• Your medical documentation: hospital records, doctor's reports, diagnostic results
• Your rebuttal of the denial reason

Keep a copy of everything you submit.

Step 3: SECP Complaint

If the insurer does not resolve your complaint satisfactorily, file with SECP's Insurance Division. The online portal is at isis.secp.gov.pk. You can file by:

• Online submission through the SECP IRIS portal
• Written complaint to SECP's Insurance Division in Islamabad or Karachi offices

SECP investigates complaints about regulatory violations and can direct insurers to comply with obligations. While SECP is primarily a regulator rather than a claims arbitrator, its involvement often prompts insurers to reconsider.

Step 4: Federal Ombudsman (Mohtasib) — mohtasib.gov.pk

The Wafaqi Mohtasib (Federal Ombudsman) handles maladministration complaints against federal government entities and, in practice, regularly accepts complaints about private insurance companies when the insurer has engaged in maladministration or unfair dealing.

Filing with the Mohtasib is free. Submit your complaint online at mohtasib.gov.pk with supporting documents. The Mohtasib can recommend settlement, investigate the insurer's conduct, and refer the matter to relevant authorities.

Step 5: Consumer Courts

For individual monetary disputes, Pakistan's consumer courts (established under consumer protection laws in each province) can hear insurance complaints. The process is more accessible than high court litigation for smaller claim amounts.

Practical Tips for Pakistani Policyholders

• Keep all original medical receipts, bills, and reports. Many Pakistani insurers require originals for reimbursement claims.
• For group employer policies, involve your HR department — they have the master policy and may be able to escalate more effectively through the group account relationship.
• File claims within the timeframe specified in your policy. Most policies require notification within 30–60 days of hospitalization.
• Learn the specific exclusions in your policy before a crisis — forewarned is forearmed.

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Related Reading:

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