Claim rejected or stuck? The escalation ladder, in order: the insurer, its grievance officer, IRDAI's Bima Bharosa portal, the Insurance Ombudsman, and consumer court.
How to complain about your health insurer
If a claim is rejected, cut or delayed, you have a clear set of steps. Each step needs the one before it, so start at the bottom and keep everything in writing.
First, read the letter
Insurers use the words "rejected" and "repudiated" loosely. What matters is the reason given and the clause it quotes. Ask for the reason in writing if the letter does not give one. Then check that clause in your own policy wording: many rejections quote a waiting period or an exclusion that does not actually apply.
Step 1: the insurer, in writing
Write to customer support with your policy number, claim number, what you want, and why. Attach the documents. Keep the complaint reference number.
Step 2: the grievance officer
Every insurer has a grievance team and a Grievance Redressal Officer, named in your policy wording. Narayana Arya, for example, lists four steps: customer support, the grievance email, the Grievance Redressal Officer, then IRDAI's portal or the Ombudsman.
Step 3: Bima Bharosa
If the insurer does not resolve it, register the complaint on IRDAI's Bima Bharosa portal at bimabharosa.irdai.gov.in. Your complaint is tracked there with the insurer.
Step 4: the Insurance Ombudsman
The Insurance Ombudsman is free and you do not need a lawyer. According to the Council for Insurance Ombudsmen, you can go to the Ombudsman if:
- you complained to the insurer first, and
- it rejected the complaint, did not reply within one month, or you are not happy with its reply, and
- you file within one year of the insurer's reply.
There is a limit on the claim value the Ombudsman can decide. Check the current limit at cioins.co.in before you file. Your policy wording also lists the Ombudsman offices.
Step 5: consumer court
You can also go to a consumer commission. It takes longer and you may want legal help.
What to keep
- The policy wording and schedule, for the year of the claim.
- The claim form, all letters and emails, and complaint reference numbers.
- Hospital bills, the discharge summary and test reports.
- The settlement or rejection letter, with the clause quoted.
Frequently asked questions
How do I complain against my health insurer?
Write to the insurer first, then its Grievance Redressal Officer. If unresolved, use IRDAI's Bima Bharosa portal or go to the Insurance Ombudsman, which is free.
When can I go to the Insurance Ombudsman?
After complaining to the insurer, if it rejected your complaint, did not reply within one month, or you are not happy with the reply. File within one year of the insurer's reply.
What is the difference between a rejected and a repudiated claim?
Insurers use the words loosely. What matters is the reason and the clause quoted in the letter. Check that clause in your policy wording.
Does the Ombudsman charge a fee?
No. Filing a complaint with the Insurance Ombudsman is free, and you do not need a lawyer.