Health Insurance Claim Rejected? How to Complain to the Insurance Ombudsman via Bima Bharosa

Scenario: Your father had an appendicitis operation, the bill was ₹1.8 lakh — and the insurer returned the claim with one line: ‘Pre-existing disease, waiting period not completed.’ You know this illness of your father’s is new. Most families give up at exactly this moment. But the law has placed a step-by-step arsenal in your hands — the insurer’s grievance cell → 30 days → IRDAI’s Bima Bharosa portal → the Insurance Ombudsman (awards up to ₹50 lakh) — all of it free.

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1. First, read the rejection letter carefully

Ask for the reason for rejection in writing — not a verbal ‘no’. The common reasons and how to test their validity:

Reason for rejection	Questions to test whether it is valid
‘Pre-existing disease’	Was the illness really before the policy? What do the medical records say?
‘Non-disclosure’ (concealed information)	Was that question even on the application form? Is there proof of what you answered?
‘Waiting period’	Which clause of the policy specifies how many days — match it against the policy document
‘Exclusion — cosmetic/non-medical’	The doctor’s written opinion on whether the treatment was medically necessary
‘Treatment not covered / room rent cap’	Is the cap calculation correct? Is a proportionate deduction — not the full bill — even the rule?

Remember: the insurer’s first rejection is not final — statistics show that a significant share of cases find relief on appeal.

2. Step 1 — Written complaint to the insurer’s grievance cell (mandatory first step)

1. Submit the complaint through the insurer’s official grievance channel (the complaint form on the website, or by registered post to the branch).
2. The complaint should include: the policy number, claim number, the date and reason for the rejection, the grounds of your objection (point by point), and what you want (full/partial claim).
3. Attach copies of all the papers: the policy, the rejection letter, hospital bills and discharge summary, prescriptions, diagnostic reports, payment receipts.
4. Keep proof of submission — a ticket number if online, a receipt if by post.

3. Step 2 — The 30-day rule and the Bima Bharosa portal

The insurer is bound by rule to resolve the complaint within 30 days. If no reply comes, or it is unsatisfactory:

1. Go to bimabharosa.irdai.gov.in — this is IRDAI’s central complaint portal (Bima Bharosa).
2. Select ‘Register Complaint’ and provide the insurer’s name, the policy number and the details of the complaint — the portal delivers the complaint directly to the insurer’s senior officer and lets you track the status.
3. For help, IRDAI’s toll-free lines: 155255 / 1800 4254 732, email: complaints@irdai.gov.in.

Many claims are resolved at the Bima Bharosa stage itself — because a complaint that reaches the regulator stays on the insurer’s audit record.

4. Step 3 — The rules for complaining to the Insurance Ombudsman

When to go: if the insurer rejects the complaint or fails to respond within 30 days, within 1 year of that.

Where: at the Ombudsman office designated for your state (Kolkata for West Bengal) — online or by post. The addresses are available on the IRDAI website.

What to attach:

• The complaint letter (what happened, what you want — briefly, with dates)
• The policy document and premium receipt
• The rejection letter and all correspondence with the insurer
• The grievance-cell complaint and its reply (proof of completing the 30-day rule)
• Medical records and bills

What happens: the Ombudsman offers an opportunity for conciliation; if unresolved, there is a hearing (now also by video conference) and an award within 30 days — up to ₹50 lakh. The insurer is bound to comply with the award; if it refuses within 30 days, under the provisions on suspended penalties its name goes on IRDAI’s record.

Caution: once you have gone to the Ombudsman, no case on the same matter will proceed in the Consumer Commission — you must choose one of the two routes. If the claim value is above ₹50 lakh, going straight to the Consumer Commission is the better route.

5. Protect yourself before the claim is even rejected

• Inform the insurer within 24–48 hours of admission (cashless pre-authorisation at a designated network hospital).
• Keep originals of all medical papers.
• Give a truthful and complete health declaration when buying the policy — Section 45’s protection does not cover false declarations either (see Term Insurance and Section 45).
• Read the policy’s exclusion and waiting-period tables in advance — from our Insurance Hub.

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Remember: a rejected claim means the fight begins, not that it ends. Every step in writing, every piece of evidence preserved — these two rules win 80% of the battle.