Insurance claim rejected or paid less? Your questions, answered

Don't treat the first "no" as final. Many rejections are overturned.

1. Get the rejection letter. It must name the exact policy clause the insurer is relying on.
2. Write to the insurer's grievance officer explaining why the rejection is wrong, with your papers. IRDAI's rules give the insurer 14 days to resolve a complaint.
3. If they reject it again, don't reply within a month, or you're not satisfied, complain to the Insurance Ombudsman. It's free and you have one year.

Keep every letter, email and bill. Send us your case for a free check and a person will tell you within 24 hours whether it's worth fighting.

The most common reasons are:

• alleged non-disclosure of an earlier illness;
• a pre-existing disease or waiting period;
• "hospitalisation was not needed" or "admitted only for investigation";
• a policy exclusion;
• missing papers.

Several of these are often wrong. Under IRDAI's 2024 health rules, no claim can be rejected just because documents are missing or the claim was intimated late. The insurer or TPA has to collect documents from the hospital itself. A rejection must also be approved by the insurer's claims review committee and must cite the policy clause.

Not for non-disclosure. After 60 months of continuous cover (the "moratorium period"), IRDAI's rules say a health policy and its claims cannot be contested for non-disclosure or misrepresentation, except for proven fraud. Years on an earlier policy you ported from count towards the 60 months. If you increased your sum insured, the 60 months for the extra amount start from the date of the increase.

Often, yes. Check four things:

• whether the "pre-existing" condition really existed before the policy started;
• whether it has anything to do with the treatment you claimed for;
• whether the waiting period is already over (IRDAI caps the pre-existing-disease waiting period at 36 months);
• whether you have crossed the 5-year moratorium.

Insurers sometimes rely on a single line in a hospital note. Your proposal form and old prescriptions are the key evidence.

Yes. Short payments usually come from deductions such as non-payable items, room-rent limits and the "proportionate deductions" that follow them, "reasonable and customary" cuts, and sub-limits. Ask for the itemised settlement letter that shows each deduction. A wrong deduction can be challenged the same way as a rejection: grievance officer first, then the Ombudsman.

With ClaimHaq, our 12% fee is only on the extra money we help recover. The ₹699 you pay when we take your case is deducted from it.

• Non-payable items: things the policy doesn't pay for, such as some consumables, toiletries and admin charges. IRDAI publishes a standard list.
• Room-rent capping: a limit on the room rent the policy pays per day.
• Proportionate deduction: if you stay in a room above your limit, the insurer may cut other room-linked charges in the same proportion. This is often where the biggest cuts come from, so these deductions are worth checking line by line.

A cashless denial is not the end of the claim. You can pay the hospital and then file a reimbursement claim with all the bills.

Under IRDAI's 2024 rules, an insurer must decide a cashless request within 1 hour, and final discharge approval within 3 hours. If discharge approval is late, the insurer pays any extra hospital charges, not you. Reimbursement claims must be settled within 15 days of submission, or the insurer owes you interest.

• Health reimbursement: within 15 days of submitting the claim.
• Cashless: within 1 hour; discharge within 3 hours.
• Your complaint to the insurer: resolved within 14 days.
• Life death claims: within 15 days of intimation, or 45 days if they need to investigate.
• Motor and property: the surveyor's report is due within 15 days, and the insurer must decide within 7 days of it.

Late payment carries interest at the bank rate plus 2%. Sources: IRDAI Master Circular on Protection of Policyholders' Interests, 2024 and the Master Circular on Health Insurance Business, 2024.

In this order:

1. The insurer's grievance officer (14 days to resolve).
2. IRDAI's Bima Bharosa portal or helpline.
3. The Insurance Ombudsman (free, up to ₹50 lakh).
4. A consumer commission, if needed.

ClaimHaq can take your case through each of these steps with you.

Bima Bharosa is IRDAI's official complaints system, at bimabharosa.irdai.gov.in. You can also use the toll-free numbers 155255 or 1800 4254 732, or email complaints@irdai.gov.in. It passes your complaint to the insurer and lets you track it. It's free and never asks for payment.

The Insurance Ombudsman settles disputes about:

• rejected or partly paid claims;
• delays;
• premium disputes;
• policies that don't match what you were promised.

It's free, you don't need a lawyer (the rules don't provide for one), and it can award up to ₹50 lakh. Individuals, sole proprietors and micro enterprises can use it. Official site: cioins.co.in.

First write to your insurer. You can go to the Ombudsman if the insurer rejects your complaint, doesn't reply within one month, or replies and you're not satisfied. You must file within one year of the insurer's reply, or within one year after that one month runs out if they never replied.

You can't use the Ombudsman if the same matter is already in a court or consumer commission. Source: Insurance Ombudsman Rules, 2017, rule 14.

The rules say the Ombudsman should pass an award within 3 months of receiving everything it needs from you. In practice, people report waits of several months to over a year, so a complete, well-organised complaint matters.

Once you accept an award, the insurer must pay within 30 days, with interest. IRDAI's 2024 rules add a penalty of ₹5,000 a day, paid to you, if the insurer pays late.

Hearings can be held in person or by video. The complaint must come from the policyholder, or their legal heir, nominee or assignee. We prepare the papers and talk you through the hearing beforehand.

An award binds the insurer. If you're not satisfied, you can still go to a consumer commission. You must file there within 2 years of the cause of action (Consumer Protection Act 2019, section 69), and the commission can accept a delay for good reason.

The Chandigarh office covers Punjab, Chandigarh, Himachal Pradesh, Jammu & Kashmir, Ladakh and most of Haryana. See its contact details and how to file.

Common reasons include:

• a licence issue;
• the vehicle being used differently from what the policy says;
• odometer or details not matching;
• late intimation;
• a lapsed policy.

IRDAI's 2024 rules say an insurer cannot reject a claim for breaking a condition that had nothing to do with the loss, or for a delay that didn't make the loss bigger. A surveyor must be appointed within 24 hours and report within 15 days, and the insurer must decide within 7 days of the report.

Ask for the surveyor's report. Most short payments come from it, often from "under-insurance" (the sum insured being lower than the value of what was covered). Losses of ₹1 lakh or more need a survey, with the same 15-day report and 7-day decision rules as motor claims. Individuals, sole proprietors and micro enterprises can use the Ombudsman. Larger businesses go to a consumer commission.

Often, yes. Common examples:

• a policy sold as a "fixed deposit";
• promised returns that aren't in the policy;
• premiums you can't afford;
• a policy that doesn't match your proposal form.

Gather the policy, the proposal form or benefit illustration you were shown, any messages from bank staff, and the bank statement showing the premiums. Then complain to the insurer, and to the Ombudsman if that fails. The Ombudsman covers policies that don't match the proposal and misrepresented terms. Act quickly: the sooner you complain, the stronger the case.

If you don't want a new life or health policy, you can return it within 30 days of receiving the policy document. The insurer must refund you within 7 days. It may keep a small amount for the days you were covered, plus medical-test and stamp-duty costs.

Not on any ground. Under section 45 of the Insurance Act, a life policy can't be questioned after 3 years from the date it was issued or revived. Before that, the insurer needs real evidence to reject a claim. Death claims must be settled within 15 days, or 45 days if the insurer investigates.

You don't have to, and we'll explain the free route to anyone who asks. People come to us because winning depends on the details:

• reading the policy and the rejection against IRDAI's rules;
• finding the right evidence;
• writing a complaint that answers the insurer's exact reason;
• keeping every deadline;
• preparing you for the hearing.

Our team of experienced insurance professionals has spent decades inside insurance companies. Apart from ₹699 when we take your case, you pay only if money comes back.

The Claim Check is free. If we take your case, there's a ₹699 fee (including GST), paid to our company account when you sign the engagement letter. If money is recovered, our fee is:

• 12% of the first ₹5 lakh;
• 8% of anything above ₹5 lakh;
• capped at ₹1.5 lakh;
• plus GST.

The ₹699 you already paid is deducted from that fee. If nothing is recovered, the ₹699 is all you pay. On ₹2 lakh recovered, you keep ₹1,71,680. Full fees and terms.

From start to finish. We read your policy and the insurer's letter and gather the right papers. Then we represent your case with the insurer's grievance team, IRDAI's Bima Bharosa and the Insurance Ombudsman, depending on what your case needs. We follow up on every reply, keep track of deadlines and prepare you for any hearing. You can see each step on your case page.

No. A person reads every case within 24 hours. If we don't think it can be won, we say so and explain why, and point you to anything you can still do for free. You pay nothing either way.

Don't accept or sign anything until you've checked it against what you're owed. Accepting a "full and final" settlement can make it hard to claim the rest. Send us the offer and we'll tell you whether it's fair. The decision is always yours.

No. Most of the work happens on WhatsApp and by phone, and our team speaks Punjabi, Hindi and English. You're welcome to visit our Chandigarh office if you prefer to meet in person. We work with clients across Chandigarh, Mohali, Panchkula and Punjab.

We never ask for an OTP, PIN or password, and the only payment we ask for before the insurer pays you is our ₹699 fee, after you've signed our engagement letter, paid only to our company account. IRDAI and the Ombudsman never charge fees either. Anyone asking for "processing charges" to release your claim is a fraud. Here's how to check it's really us. If you've lost money to a scam, call the cyber-crime helpline 1930.

Not for the insurer, Bima Bharosa or the Ombudsman. The Ombudsman's rules don't provide for lawyers. You can also file in a consumer commission yourself, though some people choose a lawyer there.