Health Claim Denied? The Legal & Practical Recovery Playbook
By regulation the insurer must provide a written rejection citing the specific policy clause. If they have not, write a formal letter demanding one and keep every communication with dates.
What not to do
Do not accept the first rejection at face value, do not miss the GRO window, and do not discard medical records or hospital bills - they are your appeal evidence.
Why claims get rejected
Non-disclosure of pre-existing diseases, incomplete waiting periods, policy exclusions, lapsed policies, delayed intimation, and missing documentation cause most rejections. The insurer must state the reason in writing - demand it if absent.
Step 2: Internal grievance (GRO)
File a formal complaint with the insurer's Grievance Redressal Officer with supporting documents. The insurer must respond within 15 days. This is the mandatory first step before external escalation.