You may have been diligently paying your health insurance premiums for years, feeling secure that your financial worries in case of an illness are covered. But one day, you fall sick, require hospitalization, and file a claim, only to face rejection. The reasons could be something like “hospitalization was not medically necessary” or some other technicality. This can be a deeply frustrating experience, and it’s natural to lose trust in your health insurance provider. Whether the company is Star Health or any other insurer, the process to raise a grievance or file a complaint is the same for all insurance companies and for all types of claims.
There are four forums where you can seek redress for your grievance, whether it’s about a rejected claim or an unfair deduction.
Before moving forward, I’m assuming you’ve already reviewed your policy document and are confident that your claim is admissible and payable as per the terms and conditions. If not, this is the first step I recommend—checking the policy in detail. But let’s not waste time; I’m assuming your claim is valid and has been denied or reduced unreasonably and without proper justification. In such a case, here’s what you should do.
Write to the Grievance Cell of the Insurance Company
Every insurance company has a Grievance Redressal Officer (GRO) whose contact details are available on their website. You can also access the list of GROs for all insurance companies here: List of GROs.
Write your complaint in simple and polite language. Always reference the specific clause in the policy that supports your claim. Insurance companies often deny claims under specific clauses, such as the “disclosure of information clause.” For instance, they might argue that your illness is linked to a pre-existing condition you didn’t disclose.
If that happens, gather all relevant documents, like past medical consultations or lab tests, that prove your stance. Share these with the Grievance Redressal Officer. Sometimes claims are denied simply due to a lack of supporting evidence, and once you provide this, the issue can be resolved. While writing, be clear and avoid using harsh language—it’s important to stay professional. Insurance companies are required to reply to your grievance within 15 days of receiving it.
Approach IRDAI’s Grievance Cell (Bima Bharosa)
If you are not satisfied with the insurance company’s response, or if you don’t receive any response within 15 days, escalate your complaint to IRDAI grievance cell Bima Bharosa.
You can register your complaint on the Bima Bharosa portal online and even by email, calling their toll-free number.
- Email IRDAI at complaints@irdai.gov.in
- Call their toll-free numbers: 155255 or 1800 4254 732
IRDAI will take up the matter with the concerned insurance company. Since IRDAI is the regulator for insurance companies, complaints routed through them are often taken more seriously. Therefore, the chances of getting a meaningful resolution through the Bima Bharosa portal are higher than pursuing the matter on your own.
Approach the Insurance Ombudsman
If you’re still not satisfied after Steps 1 and 2, you can escalate the matter to the Insurance Ombudsman or take legal recourse. But keep in mind that you can’t do both at the same time.
To approach the Ombudsman:
- Wait at least 30 days after filing your grievance with the insurance company.
- File your complaint online at https://www.cioins.co.in/.
Choose the Ombudsman office nearest to your residence or as per your convenience (refer to your policy document for the address). The Ombudsman is well-versed in insurance matters and provides a quick resolution, often within a single hearing. This forum is a better option for faster resolution compared to courts.
Legal Recourse
If you’re not satisfied with the outcomes of the above three mechanisms, you can take legal action by approaching the Consumer Court or Civil Court.
- Consumer Court: Cases in consumer courts may take time, but they often more favorable to policyholders considering the broader application of laws and fairness principles.
- Civil Court: This option is more time-intensive and should be considered only if all other mechanisms fail.
Prevention is Better Than Cure
One of the simplest yet most overlooked steps is thoroughly reading the policy document before making a purchase. Since you’re paying a hefty premium every year, it’s only fair that you understand the policy’s inclusions and exclusions clearly.
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Here’s why this is so important: If a claim is rejected due to a clause explicitly mentioned under exclusions, there’s little chance of overturning the decision, even through grievance redressal mechanisms. Knowing these exclusions upfront can save you a lot of frustration and disappointment later.
However, if your grievance is unrelated to the exclusions there’s still hope. Always review the grounds for rejection carefully before proceeding with a resolution.
How to Avoid Claim Rejections
- Choose Reputable Insurers: Buy your policy from well-established insurance companies with a strong track record of low claim rejections and fair claim settlement practices. Even the best policy is of little value if the insurer is known for denying or deducting large claims unfairly. A great health insurance product isn’t just about the features—it’s also about the company’s commitment to honoring its promises.
- Keep it Simple: Always opt for a straightforward health insurance policy. Policies packed with too many features and offers can often be confusing and aren’t necessarily the best choice. Choose a policy that you can easily understand by reading the document without needing extensive explanations. Don’t fall for flashy marketing tactics or promises of unbelievable coverage at suspiciously low premiums—these should raise a red flag
- Full Disclosure of Medical History: Always declare all pre-existing or past medical conditions when buying a policy. Never hide any details thinking the insurer won’t find out. These companies are highly professional and have robust systems to detect discrepancies. Hiding information breaches trust, and insurers take such violations very seriously.
- Choose Network Hospitals: For planned hospitalizations, stick to the insurer’s network hospitals. The list is easily available on their website. Before undergoing surgery, contact your insurance company’s customer care to confirm the rates they have agreed upon with the hospital for that specific procedure. Once you have this information, discuss and negotiate with your doctor to ensure the charges align with these agreed rates. This can help you avoid unnecessary out-of-pocket expenses and ensure that your claim is processed smoothly. Avoid paying extra out of pocket, expecting reimbursement later—it’s risky and often doesn’t work out.
- Understand the Purpose of Insurance: Health insurance is designed to cover unforeseen and sudden medical events. Not all hospitalizations are covered. For example, treatments that can be managed with oral medication at home are unlikely to be reimbursed. Don’t misuse your policy just because you have one; reserve it for genuine needs.
Fighting Unjustified Claim Rejections
If you’re confident that your claim has been denied or deductions made on unfair grounds, don’t hesitate to fight for what’s rightfully yours. Sometimes, the claim approval process just needs your persistence and intervention. If your reason is valid and justified, take the matter to the end—you might be surprised at the outcome.
Health insurance isn’t just a financial product; it’s a lifeline. Use it wisely, understand it fully, and don’t give up where it truly matters.
