Paying premium for years and then facing a rejected claim is frustrating. The good news is that most rejections happen for reasons that can be avoided.
Common Reasons for Rejection
Non-Disclosure of Medical History
Hiding a pre-existing disease, even by mistake, is the most common cause of claim disputes. Always state your medical history correctly on the proposal form.
Claim During the Waiting Period
If you claim for a condition that is still under a waiting period, the claim will be rejected.
Policy Lapse
If you miss renewal and the policy lapses, hospital bills during the gap will not be paid.
Treatment Not Covered
Cosmetic procedures, some dental work, infertility treatment and many other treatments are excluded in most plans.
Incomplete or Late Documents
Missing bills, discharge summary or reports can delay or cancel a claim. Submit within the time limit.
Hospitalisation Not Required
If a treatment could have been done on an outpatient basis, the insurer may reject the claim.
How to Avoid Rejection
- Read the policy wording, especially exclusions.
- Disclose everything honestly during purchase.
- Renew before the due date.
- Inform the insurer or TPA quickly.
- Keep all bills, prescriptions and reports safe.
What If Your Claim Is Rejected?
Ask for the reason in writing, write to the insurer’s grievance officer, and if you are unsatisfied, approach the Insurance Ombudsman. It is a free service for policyholders.
Frequently Asked Questions
Can I challenge a rejected claim?
Yes. Start with the insurer’s grievance cell, then the Insurance Ombudsman, and finally consumer court if needed.
How long does the Ombudsman take to decide?
It generally takes a few months, but timelines vary.
Does a rejected claim affect my policy?
Not automatically, but a proven fraud can lead to policy cancellation.
