Why health insurance claims get rejected
The insurer has to give you the reason in writing. These are the reasons we see most often:
- Pre-existing disease. The insurer says the illness existed before the policy began and its waiting period is not over. Under IRDAI’s 2024 rules, this waiting period cannot be longer than 3 years.
- Waiting period. Most policies do not pay for illness in the first 30 days (accidents are covered), or for listed conditions such as cataract or hernia for a fixed period. Time already served on an earlier or ported policy counts.
- Non-disclosure. The insurer says a health condition was not declared in the proposal form. After 5 years of continuous cover, called the moratorium period, a claim cannot be contested on this ground unless there is proven fraud.
- “Not medically necessary”. The insurer says the treatment could have been given without admission. Your treating doctor’s notes are the main evidence here.
- Exclusions. The treatment falls under an exclusion listed in the policy, such as cosmetic treatment.
- Documents or deadlines. Papers were missing, or the insurer was informed late.
Many rejections rest on a narrow reading of one clause. Reading that clause next to your medical records is where most cases are won.
What to do, step by step
- Read the rejection letter. Note the clause number and the exact reason. If the reason is vague, ask the insurer or TPA to state it in writing.
- Collect your documents. Policy schedule and wording, a copy of your proposal form, the rejection letter, discharge summary, bills, test reports, doctor’s notes and every email or letter exchanged with the insurer.
- Check the reason against your policy. Was the waiting period already over? Was the condition really pre-existing, or diagnosed after cover began? Does the exclusion actually apply to this treatment?
- Write to the insurer’s grievance cell. Answer the rejection point by point and attach evidence, such as a certificate from your treating doctor. Insurers must acknowledge a complaint within 3 working days and resolve it within 14 days.
- Escalate if needed. Register the complaint on Bima Bharosa. If the insurer rejects your complaint or does not reply within a month, you can go to the Insurance Ombudsman within a year. See how the Ombudsman works.
Mistakes that weaken a case
- Arguing in general terms without quoting the clause the insurer relied on.
- Sending documents that contradict what was submitted earlier, such as a different date of first diagnosis.
- Waiting too long. The Ombudsman route closes one year after the insurer’s reply.
How Mediclaimswala helps
Our team has worked inside the insurance and healthcare sector, so we know how claims are assessed. We read your letter and policy line by line, tell you honestly whether the case is worth pursuing, draft and file the representation, and follow up through the grievance cell and the Ombudsman until it is resolved.
Last reviewed: . This page is general information based on IRDAI rules as of the date above. It is not legal advice. Policy wordings differ, so we check what applies to your case.