Procedure to Appeal against Denied Health Insurance Claim


Health issues can lead to severe stress, because it affects the patient as well as the family members. In a situation like this, you can only think of one option, i.e. purchasing a health insurance policy. It acts as a support system, but it can also lead to severe trauma if the health insurance claims gets rejected. Health insurance companies can indeed reject claim applications. However, there is still an option of appealing against a declined claim.

Reason for claim rejection

When insurance companies reject a health insurance claim, they do have a strong reason for doing the same. Most of the times, the reasons are not even communicated when the claim application gets rejected. At such times, you can ask for it; and once you know the cause of your claim rejection, you can also make amends and reapply.

After the claims team receives an application, the first thing they do is check for the policy details of the applicant. Names of people covered, policy validity, and inclusions are some necessary details that are checked and verified.

Mentioned-below are some significant issues that the claims team face, which leads to claim rejection:

  • When you raise a claim for an issue which isn’t covered under the policy.
  • When a claim is raised, and the policy is expired.
  • You forget to mention the necessary details in the claim application.
  • If you miss out on providing supporting documents.
  • If you raise a claim for someone, who isn’t a part of the policy.

Rectifying and applying again

It becomes easier if you already know the reason for claim rejection, as you can rectify and reapply. But, if you raised a claim for an expired policy or any other similar instances, then the claim shall not be accepted. Get in touch with your insurance company’s executive and understand the reason for rejection and how you can rectify it. This can also be done by making a call or sending an email.

Ombudsman approach

The Government of India created the Insurance Ombudsman for helping you to settle complaints. To raise a complaint against your insurer, write to the Ombudsman of your location. Your complaint could be about a delay in claim settlement, premium dispute, misrepresentation of terms and conditions, and other issues concerning the Insurance Act, 1938.

The Ombudsman approach is said to be an impartial as well as an out of the court system. It acts as a mediator between you and the insurer if any complaint arises, and it arrives at a good recommendation based on the available facts.

How to ensure this never happens?

It is better to read and understand the terms and conditions of a policy before you purchase it and raise an insurance claim for it. Like this, you won’t face trouble in case of a wrongly purchased policy or improperly filed claim. Always analyze your requirements and purchase a policy that covers all your needs; this would be a proactive approach to buying a health insurance policy. The policy document will have the inclusions as well as the exclusions of the policy mentioned.

Buying health insurance online

Purchasing of health insurance plans online have made the entire process hassle-free unlike earlier when you had to visit the insurer’s branch office for relying on an agent for the policy. There was also a risk, as the personal details could be misrepresented because they were the ones filing application forms.

However, now that there are online insurance plans available, you don’t have to face these issues anymore. You can read and understand the inclusions and exclusions of the policy on your own. The information conveyed is in a transparent and straightforward matter in the online method. Also, the chances of misrepresentation are less because you are the one providing information. Now you can also compare between policies such as health insurance plans for family or individual health insurance online.


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