Health Insurance Claim Rejection — Advocate at Asansol Court

The most common grounds are the waiting period for pre-existing diseases, a claim filed within the initial waiting period of a new policy, a treatment the policy excludes, a non-disclosure of a medical condition when cover was bought, or a dispute over whether the hospitalisation was medically necessary. Each ground turns on the policy wording and the facts, and insurers must give the specific reason, not a vague refusal. A rejection that fails to state the specific ground is difficult for the insurer to defend and is itself a reason for the patient to press the matter further.

Some rejections are partial: the insurer pays part of the bill and disallows deductions for room rent, consumables or specific procedures. A patient should read the rejection letter carefully and match each ground to the policy's terms. If the insurer has relied on a condition that does not exist in the policy, or has ignored documents already submitted, the rejection can be challenged with the material on record.

Policies usually impose a waiting period before they cover conditions that existed before the policy was bought, and this is a frequent source of dispute. The insurer must show that the condition was pre-existing and that the waiting period had not run out. Regulators have moved to standardise and limit how long these waiting periods may be, so the terms of the individual policy must always be checked.

Where the insurer alleges non-disclosure, the question is whether the information was material and whether the insurer was misled. A condition that was never diagnosed, or a routine check-up that revealed nothing, is not the same as concealing a known illness. Medical records from treating doctors help establish when the condition was first diagnosed, which is often the decisive fact. The proposal form the patient signed when buying the policy is the key document in these disputes, and a copy should be obtained from the insurer.

The first step after a rejection is a written representation to the insurer's grievance officer. State the policy number, the claim number, the date of hospitalisation and the exact reason given for the rejection, and explain why it is incorrect, attaching the discharge summary, investigation reports and any clarification the treating doctor can give. Ask for a written decision within the period the regulator requires. The grievance officer's role is to examine the claim afresh, and a clear, well-organised representation with a covering index of documents is more likely to produce a reasoned reply.

If the grievance officer upholds the rejection, the reply is itself useful, because it fixes the insurer's position for the next stage. If the insurer does not respond at all within the time allowed, that failure is a ground of complaint in itself. Keep copies of the claim form, the rejection letter and all correspondence, as both the ombudsman and the consumer commission will examine the paper trail.

The Insurance Ombudsman provides a free and relatively quick remedy for many claim disputes, including a wrongful repudiation of a claim and a delay in settling it. A complaint may be filed with the ombudsman having jurisdiction over the area, and for Asansol that is the office at Kolkata. Complaints must generally be made within the period allowed after the insurer's final decision, so the grievance stage should not be allowed to drag.

The ombudsman examines the papers and may pass an award settling the dispute. Because the process is free and does not require a court appearance, it is often the most practical route for a rejected health claim. However, the ombudsman cannot entertain every kind of dispute, and a complainant should confirm that the matter falls within the scope before filing.

Where the ombudsman route is unavailable or a claim needs compensation beyond the ombudsman's limits, a consumer complaint can be filed before the District Consumer Disputes Redressal Commission for Paschim Bardhaman at Asansol. A deficiency in service by the insurer, or an unfair trade practice in selling the policy, can be the basis. The commission can order the claim to be paid and grant compensation for the hardship caused. The complaint should be filed in the format prescribed by the consumer law, with an affidavit and the fee, and within the limitation period.

A complainant should file within the limitation period allowed under the consumer law, with the policy, the claim documents, the rejection letter and the grievance correspondence. Free legal aid for eligible patients can be sought from the District Legal Services Authority at Asansol. Because the deadlines at each stage matter, a patient dealing with a rejection should not delay before seeking advice.