Updated on 23 Dec 2025
The health insurance policy is known to offer financial relief during various medical emergencies. However, countless policyholders in the nation have experienced disappointment when their claims were rejected. A denied claim will not just lead to stress but also cause unforeseen monetary pressure. Uncovering why the claim got dismissed and the steps you must take afterwards can save you from other issues. With the correct awareness, you can also lower the chances of denial in the future. Let’s find out more from this blog.
What is a health insurance claim rejection?
A health policy claim rejection takes place when the insurance firm refuses to pay for the medical costs under the policy. This can happen for countless reasons like blunders in the claim process, incomplete documents or policy exclusions. A denial doesn’t mean you’re helpless; it simply means that you must understand the reason behind it and look for ways to correct or appeal the issue.
Common reasons for health insurance claim rejections
Below are some common reasons why health policy claims get dismissed in India:
- When you submit incorrect or incomplete documents.
- Fail to disclose the pre-existing medical issues at the time of purchasing the plan.
- Claiming for treatments that are not covered under the health plan.
- Making the claim before the waiting period is over.
- Delayed in notifying the insurance firm or the hospital about the hospitalisation.
- Exceeding the sum limits or insured amount mentioned in the plan.
Steps to take when your health insurance claim gets rejected
Wondering what to do if health insurance denies claim? Refer to the below process for a clear picture on how to deal with it:
1. Understand the Cause or Basis for Rejecting a Claim
- Your claim pertains to a disease or treatment not encompassed by the policy's coverage.
- The policy has lapsed or is no longer valid.
- Insufficient details in the application form hinder the support for your claim.
- Inadequate proof or essential documents have not been provided as stipulated.
- The claim is for an individual not included in the policy coverage.
2. Amend and reapply as needed
- Make necessary changes and restart the claim process.
- Contact the insurance company to confirm adequacy of added details before resubmitting.
3. Contact an Ombudsman for assistance
- Insurance Act, 1938, permits policyholders to approach Ombudsman for claim settlements, premium discrepancies, policy term violations, or unclear terms.
- Appointed by insurance companies, Ombudsman mediates for dispute resolution between policyholders and insurance companies.
- Verifies facts and issues fair recommendations.
- Keep relevant documents (bills, policy copies, payment receipts, KYC documents) to support the claim.
4. Draft an appeal letter to address the insurance company.
- Craft a compelling appeal letter or email to address a rejected health insurance claim.
- Explain the reason for obtaining the insurance policy and the specific medical condition involved.
- Provide details about the recommended treatment plan from your healthcare professional.
- Include evidence such as medical prescriptions to support your case.
- Ensure the letter contains factual and necessary information.
- Write why you believe the insurance company should reconsider the appeal against the denied claim.
Tips for preventing health insurance claim rejections
When you want to avoid the stress of getting the senior citizen health insurance claim rejected, you should remember the following pointers:
- You must always disclose pre-existing health conditions honestly when purchasing a health plan.
- Check the hospital’s connection with the insurance firm for a smooth and cashless claim.
- Go through the policy document properly to understand what is excluded and included in the plan.
- Keep all the medical bills, hospital reports, and prescriptions safe.
- Inform the insurance company about the hospitalisation within the given time frame.
Conclusion
A denied claim can be pretty frustrating, but that doesn’t mean it's the end of the path. Having good knowledge about your rights and then taking the correct steps can sometimes get the claim approved. Apart from that, honest communication and proper planning can help you prevent such unwanted issues. While you keep the focus on securing the health of yourself and your family, allow us to ensure your finances. Receive customised health insurance-related advice and even solutions by filling the form on this page. A small preparation today will enable you to safeguard from big issues tomorrow.
Disclaimer: The information provided in this blog is for educational and informational purposes only. It is not intended as a substitute for professional advice, diagnosis or treatment. Please consult a certified medical and/or nutrition professional for any questions. Relying on any information provided in this blog is solely at your own risk, and ICICI Lombard is not responsible for any effects or consequences resulting from the use of the information shared.