Health insurance
Health insurance claim rejected? What to do.
Last updated 23 October 2026.
The short answer. If a health insurance claim is rejected, cashless is denied, or the settlement is delayed, ask for the reason in writing, answer it point by point, and escalate in order: the insurer, its grievance officer, Bima Bharosa, then the Insurance Ombudsman. Keep the hospital papers and every letter.
Your options
Your options, in order.
The same ladder applies to a mediclaim rejection, a cashless denial or a deduction.
- 1. Get the reason in writing. For a cashless denial or a rejection, ask the insurer or the TPA for the written reason and the clause relied on.
- 2. Write a point-by-point reply. Answer each reason with the policy wording and your hospital papers.
- 3. Escalate to the grievance officer. Attach the first reply and any response.
- Register on Bima Bharosa. This is IRDAI’s online grievance portal. It states that a registered complaint will be attended to within 14 days.
- Approach the Insurance Ombudsman. If the insurer has rejected your complaint, has not replied within a month, or the reply is not acceptable, you can complain to the Insurance Ombudsman within one year. There is no fee, and compensation sought should not exceed ₹50 lakh.
Documents to keep
- Policy document, schedule and any riders
- Discharge summary, bills and prescriptions
- Investigation and diagnosis reports
- Pre-authorisation request and the denial, if cashless
- Earlier policies and portability papers, if any
- Every letter and reply
Reasons given
Common reasons, and what to check.
The stated reason decides what your reply must address.
- Pre-existing disease. Check the policy definition and whether the condition was diagnosed or treated before the policy began.
- Non-disclosure. Check what the proposal form asked and what you answered.
- Waiting period. Check the period in your policy and the date the condition arose.
- Cashless denied. A cashless denial is not always a final rejection. You can ask for reimbursement review with the papers.
- Deductions or short settlement. Ask for the break-up and the clause for each deduction.
- TPA delay. Note the dates of each query and reply; they matter in a complaint.
How Samadhan Sarathi helps
We prepare it, step by step.
We read the papers against the policy wording, prepare your grievance and escalation letters, and, where it comes to that, prepare the Ombudsman petition. You sign it and return it, and we submit it online. A team of specialists works your file, supported by AI-assisted review of the policy and the correspondence.
Our fee
- 12% of what we recover for you
- GST included
- Nothing payable upfront
Who we are. Samadhan Sarathi is a private service based in Ludhiana. We are not the government, not the insurer, not a bank, and not IRDAI or the Insurance Ombudsman. We prepare your papers and take you through the process.
Questions
Common questions.
Cashless was denied at the hospital. What now?
Ask for the written reason, then you can pay and claim reimbursement with all papers, and challenge the denial through the insurer’s grievance route.
What are common reasons for health claim rejection?
Pre-existing disease, non-disclosure in the proposal form, waiting periods and missing documents are the most common.
Can I complain against a TPA?
Yes. Write to the insurer and its grievance officer with the TPA correspondence attached.
What if the insurer deducts part of the claim?
Ask for the break-up and the policy clause for each deduction, and challenge any you disagree with in writing.
Where can I complain after the insurer replies?
Bima Bharosa, and then the Insurance Ombudsman, free of charge, for compensation up to ₹50 lakh and within one year.
Will Samadhan Sarathi get my claim paid?
We cannot promise any outcome. We prepare your papers and take you through the process.
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