Insurance Claim Rejected? Here's What To Do
A written rejection is not the final word. Under IRDAI rules, every policyholder has a structured right to appeal — through the insurer's grievance cell, the Insurance Ombudsman, and Consumer Commissions. This guide walks through the real reasons claims get denied and the exact steps to reopen one.
Common reasons insurers reject a claim
Non-disclosure of pre-existing disease
Insurers often reject health claims citing undisclosed medical history at the time of policy purchase. A rejection on this ground is contestable if the condition was unrelated or the claim falls outside the moratorium period under IRDAI rules.
Delay in intimation
Motor and health policies require the insurer to be informed within a stated window. Delay alone is not always a valid ground for rejection — case law recognises reasonable cause.
Policy exclusion cited
Insurers frequently rely on fine-print exclusions. Many exclusions have been narrowed by IRDAI's standard health-insurance product norms and by consumer forum orders.
Documentation shortfall
Missing discharge summary, FIR, indoor case papers, or original bills. Most of these can be reconstructed and re-submitted with a proper representation.
Waiting period / sub-limit
Rejections invoking waiting periods, room-rent capping, or disease-wise sub-limits should be checked against the exact policy wording — insurers sometimes apply the wrong clause.
Suicide, intoxication or fraud clause (life/motor)
Repudiation on these grounds requires the insurer to prove the exclusion. If proof is thin, the claim can be reopened through the ombudsman or consumer forum.
Step-by-step: how to challenge a rejection
Get the rejection letter in writing
Ask the insurer for a written repudiation letter that quotes the exact clause used. Verbal or SMS rejections are not sufficient for appeal.
File an internal grievance
Every insurer has a Grievance Redressal Officer. IRDAI requires a written response within 14 days. Keep the acknowledgement.
Escalate to the Insurance Ombudsman
If the insurer does not resolve within 30 days, you can file a free complaint with the Insurance Ombudsman for claims up to ₹50 lakh (per IRDAI's Insurance Ombudsman Rules, 2017 as amended).
Consumer Forum / Civil Court
For amounts above the ombudsman limit or when the ombudsman order is not acceptable, a District / State Consumer Commission complaint is the next step.
Insurance Ombudsman — what to know
- Filing is free of cost for the policyholder.
- Covers claims up to ₹50 lakh (Insurance Ombudsman Rules, 2017 as amended).
- Must be filed within 1 year of the insurer's final rejection.
- The insurer is bound by the ombudsman award if you accept it.
Frequently asked questions
Can a rejected insurance claim be reopened?
Yes. A written repudiation is not final. You can file a representation with the insurer's grievance cell, and if unresolved within 30 days, approach the Insurance Ombudsman. Many rejected health and motor claims are settled at the ombudsman stage.
How long do I have to challenge a rejection?
You have up to 1 year from the insurer's final rejection letter to approach the Insurance Ombudsman (Rule 14 of the Insurance Ombudsman Rules, 2017). Consumer Commission complaints have a 2-year limitation from the date of the cause of action.
Is the Insurance Ombudsman free?
Yes. Filing with the Insurance Ombudsman is free of cost for the policyholder. No lawyer is required, though many people prefer expert representation while drafting the complaint.
What documents do I need to appeal?
The written rejection letter, your policy document, the original claim form, all medical / accident / loss documents already submitted, and proof of premium payment. Any correspondence with the insurer's TPA or surveyor is also important.
Do you handle claims outside Odisha?
Yes. ClaimForSure works pan-India. All communication with insurers and the ombudsman can be done remotely once we have your documents.
Send us your rejection letter
First review is free. Our team will read the repudiation, cross-check the clause against your policy, and tell you honestly whether an appeal is likely to succeed.
This page is general information about the claim appeal process in India and is not legal advice. ClaimForSure is operated by Sidheshwar Enterprises and assists policyholders with representation before insurers, IRDAI, and the Insurance Ombudsman.