Your insurance claim has been rejected. The company has sent you a letter citing reasons like 'non-disclosure', 'policy exclusion', 'waiting period', or 'material misrepresentation'. It feels final. But it is not.
Most insurance claim rejections are not legally sustainable. Here is what you can do.
Common Rejection Grounds โ and Why They Fail
1. Non-Disclosure
Insurance companies often cite 'non-disclosure of pre-existing conditions' to reject claims. However, under IRDAI's incontestability clause, a policy that has been in force for 3 years or more cannot be repudiated except in cases of fraud. Even within 3 years, the company must prove the non-disclosure was material (relevant) to the claim.
2. Policy Exclusion
Many companies cite exclusions that are either not in the actual policy document or are being incorrectly applied. Always check the exact wording in your policy.
3. Waiting Period
Health insurance waiting periods apply only to specific conditions. Companies sometimes apply them broadly to reject claims. The waiting period clause must be specific and applicable to your exact claim.
The Legal Route โ Step by Step
- Step 1 โ GRO Complaint: File with the company's Grievance Redressal Officer. They must respond within 30 days.
- Step 2 โ IRDAI Bima Bharosa: If GRO response is unsatisfactory, escalate to IRDAI's online portal.
- Step 3 โ Insurance Ombudsman: Free to file. Binding order within 90 days. Company cannot appeal.
- Step 4 โ Consumer Forum: Filing costs โน200. Can award original claim + harassment compensation.
Act Quickly โ Timelines Matter
The Ombudsman complaint must be filed within 1 year of the company's rejection. Consumer Forum limitation is generally 2 years. Do not wait.