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File the claim through the procedure in your policy, preserve proof that you submitted every required document, and ask for any denial or reduction in writing. If the insurer’s answer is wrong or incomplete, challenge it first with the insurer’s Grievance Redressal Officer (GRO), then use IRDAI’s Bima Bharosa grievance system, and consider the Insurance Ombudsman when the scheme’s eligibility rules are met.
Your policy wording, schedule, endorsements and the facts of treatment control whether a claim is payable. No general checklist or appeal route can override exclusions, waiting periods, limits, notice conditions or other terms in your contract.
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What governs a health-insurance claim
The policy is the starting point. Check the policy schedule, definitions, exclusions, waiting periods, sub-limits, co-payment, deductibles, renewal status and the claim-procedure section. Also check whether your policy requires advance notification, pre-authorisation, treatment at a specified type of facility, or particular forms. The insurer or its third-party administrator (TPA) can tell you which documents and channel apply to the specific claim.
IRDAI’s health-insurance FAQ states that a denial or repudiation communication must be made by the insurer, state the reasons and refer to the corresponding policy conditions, while also giving the grievance procedure. A TPA may handle administration, but ask the insurer for the formal decision and the clause relied on.
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How to file a health-insurance claim
1. Confirm the route and notification requirement
Read the claim instructions before sending anything. Your policy may distinguish between a cashless request arranged through a network hospital and a reimbursement claim that you pay first and submit later. It may also set different notification or pre-authorisation steps for planned and emergency treatment. If an emergency prevented advance notice, explain the circumstances and provide the earliest available notification evidence.
2. Build a complete working file
There is no single official document list that fits every insurer and claim. Use the insurer’s current form and portal instructions, then gather documents relevant to the treatment and the disputed amount. A practical file commonly includes:
- Policy number, health card and claimant identification details.
- Completed claim form and any pre-authorisation or discharge forms.
- Itemised hospital bills, final bill, payment receipts and deposit records.
- Discharge summary, admission and discharge dates, and treating doctor’s notes.
- Prescriptions, diagnostic reports, consultation notes and operative records where relevant.
- Pharmacy receipts and invoices for medicines connected with the treatment.
- Proof of payment for reimbursement claims.
- Notification emails, portal acknowledgements, TPA messages and all correspondence.
This is a working checklist, not an exhaustive legal or regulatory list. Keep scans or photocopies and retain originals unless the insurer specifically requires an original and gives you a receipt.
3. Submit through the specified channel
Use the portal, email, branch or TPA channel identified in your policy or claim instructions. Upload readable files, use consistent filenames and record the submission date, time, reference number and the documents sent. If you submit physically, ask for a dated acknowledgement. If you send by post, keep the receipt and delivery confirmation.
4. Track requests and respond precisely
Insurers may ask for clarification or additional records. Answer each request in writing, attach only relevant material and list the attachments. If a requested record does not exist, state that clearly and explain why. Keep a chronology showing the request date, your response date and any follow-up.
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What to do when a claim is denied, reduced or delayed
Read the decision, not just the payment figure
Obtain the written settlement or repudiation letter. Identify:
- Whether the claim was rejected in full, partly allowed or left pending.
- The amount claimed, amount paid and each disallowed item.
- The stated reason and the exact policy condition or exclusion cited.
- Any missing document or further action requested.
- The insurer’s grievance contact and escalation instructions.
IRDAI’s stated standard is that a denial or repudiation must specifically state the reasons and refer to the corresponding policy conditions. If the letter gives only a generic phrase, ask the insurer to identify the clause and explain how it applies to your treatment and documents.
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Compare the decision with the policy schedule and wording, endorsements, medical records, bills and your submission acknowledgements. Address the specific issue rather than arguing that the claim is “genuine” in general. For example:
- Missing document: attach the record or explain why it cannot be obtained, and ask whether an alternative is acceptable.
- Exclusion or non-payable item: quote the relevant wording and explain why the billed service does not fall within it, if your records support that position.
- Waiting period or pre-existing condition: provide policy inception, renewal and medical-history records relevant to the dates in question.
- Non-disclosure allegation: request the proposal answer, medical evidence and clause on which the allegation is based.
- Medical-necessity or treatment dispute: provide the treating doctor’s explanation and clinical records, without altering or selectively editing them.
- Limit, sub-limit, co-payment or deductible: ask for the calculation showing how the insurer arrived at the allowed amount.
Do not assume that one of these examples is the reason in your case. The written decision and policy wording must establish that.
For a delay, establish the last-document date
Keep proof of when the insurer received the last document it requested. An IRDAI FAQ describes, in the circumstances covered there, interest at 2% above the bank rate from receipt of the last necessary document until payment. It also describes investigation completion within 30 days and settlement within 45 days from receipt of the last necessary document where an investigation is warranted. These provisions depend on the applicable regulations and facts; ask the insurer to state which rule and date it used before treating an interest calculation as payable.
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Appeal first to the insurer’s Grievance Redressal Officer
The insurer’s GRO is the first formal appeal step. Address the complaint to the GRO for the branch or office concerned, following the insurer’s published contact details. Submit it in writing with supporting documents and obtain an acknowledgement bearing the date.
What to include
- Policy number, claimant name and contact details.
- Claim or pre-authorisation reference number.
- Hospital, treatment and admission or service dates.
- Amount claimed, amount paid and amount rejected or held.
- Date of the denial or settlement letter.
- The exact reason you dispute and the policy condition cited.
- A short, dated chronology of notification, submission, requests and replies.
- The remedy requested, such as reconsideration, payment of a specified balance, correction of a calculation or a reasoned decision.
- An attachment index and copies of the records that support each point.
Attach the denial or settlement letter, relevant policy pages, claim form and acknowledgement, medical records and bills tied to the disputed issue, and earlier correspondence. Keep a complete copy of what you send. The IRDAI/Bima Bharosa FAQ says the insurer should resolve a complaint within 15 days of receipt. Record the date from which that period is being counted and follow up using the complaint reference.
Make the appeal easy to verify
Use headings that mirror the insurer’s reasons. For each issue, state the clause, the fact, the supporting document and the remedy sought. Avoid accusations, altered records or unrelated medical history. Ask the GRO to confirm in writing if any document remains outstanding.
Escalate through IRDAI’s Bima Bharosa
If the insurer’s response is unsatisfactory or the complaint is not resolved in the indicated period, register a complaint through IRDAI’s Bima Bharosa (IGMS) system. The available routes described by Bima Bharosa include its online portal, toll-free number 155255, email [email protected] and postal complaint.
A Bima Bharosa registration is sent to the insurer and recorded in IRDAI’s repository. The FAQ says the system generates a trackable token, mirrors status updates and makes the insurer’s final resolution available in the complainant login. Upload the GRO complaint, acknowledgement, decision letter, policy extracts and the evidence that answers the disputed reason. Keep the token and screenshots or downloaded copies of status messages.
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Understand the different Bima Bharosa time statements
Official pages use different clocks for different purposes:
| Statement | What it relates to | How to use it |
|---|---|---|
| 15 days | The insurer-grievance FAQ’s stated period for resolving a complaint after receipt. | Count from the insurer’s recorded receipt of your GRO complaint. |
| 14 days | A live Bima Bharosa portal banner says a complaint will be “attended to within 14 days.” | Treat this as a portal service statement, not a promise that the claim will be paid or finally adjudicated. |
| 15 days after Bima Bharosa registration | The Bima Bharosa process page says the Ombudsman may be approached if the complaint is not attended within 15 days of registration or the insurer’s resolution is unsatisfactory. | Keep the portal registration date and insurer response when deciding whether to move to the next forum. |
These periods are not interchangeable. A portal acknowledgement, an insurer’s final decision and an Ombudsman filing condition can be triggered by different events.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.When the Insurance Ombudsman may be available
The Ombudsman is a possible next forum for an eligible individual policyholder after approaching the insurer. IRDAI’s Ombudsman information describes eligibility where the claim has been rejected, the resolution is unsatisfactory or there has been no response for 30 days. It specifically includes partial or total repudiation of health-insurance claims and reports a ceiling of ₹30 lakh for the claim, including expenses claimed.
The Ombudsman route is tied to the office with territorial jurisdiction and to the Insurance Ombudsman Rules. Before filing, verify the current jurisdiction, application method, filing window, exclusions, required documents and claim-value calculation on the current IRDAI or Council for Insurance Ombudsman information. The 30-day no-response condition applies to the Ombudsman scheme’s stated trigger after first approaching the insurer; it is not a universal waiting period that replaces an earlier rejection or an unsatisfactory written resolution.
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- Your policy schedule and relevant wording or endorsements.
- Claim form, hospital records, bills and payment proof.
- The insurer’s repudiation or settlement letter, or evidence of no response.
- GRO complaint, dated acknowledgement and reply.
- Bima Bharosa token and status or resolution records, if used.
- A concise chronology and a statement of the relief sought.
Submit only the documents and facts relevant to the dispute. Check the current scheme before relying on the ₹30 lakh ceiling or any filing deadline, because procedural rules can change.
Which forum should you use?
| Forum | Who handles it | When to use it | Primary role | Key evidence |
|---|---|---|---|---|
| Insurer GRO | The insurer’s designated grievance officer. | Immediately after a denial, reduction, delay or unresolved claim issue. | Internal reconsideration and a reasoned response. | Policy, decision letter, claim file, medical records, bills and acknowledgement. |
| Bima Bharosa | IRDAI’s grievance platform, with the complaint routed to the insurer. | When the insurer response is unsatisfactory or the stated period has passed. | Regulatory grievance facilitation, tracking and visibility of the insurer’s resolution. | GRO complaint, receipt, insurer reply, token and supporting documents. |
| Insurance Ombudsman | The Ombudsman with territorial jurisdiction. | After first approaching the insurer, when the scheme’s rejection, unsatisfactory-resolution or no-response conditions are met. | Eligible dispute redress under the Ombudsman Rules. | Complete claim and grievance record, proof of insurer approach and evidence of the disputed amount. |
Common failure points and practical fixes
The insurer says the file is incomplete
Ask for a written, itemised list of missing records and the policy or claim instruction that requires each one. Send what you have, explain any unavailable item and request a decision on the remaining evidence rather than allowing an open-ended request cycle.
The payment is lower than expected
Request the calculation: billed amount, non-payable items, sub-limits, deductible, co-payment, excluded charges and the final amount. Compare each adjustment with the schedule and wording. Appeal only the adjustments you can support with documents.
You received only a TPA message
Ask the insurer for the formal denial or settlement communication and the policy clause. Preserve the TPA message because it may establish dates and reasons, but do not treat an informal call or chat as the final written decision.
You missed a notice date
Notify the insurer immediately, explain the reason for the delay and provide evidence such as emergency admission records. Whether late notice defeats the claim depends on the policy wording and circumstances; do not assume an automatic waiver or automatic rejection.
The insurer requests originals
Provide originals only through a traceable channel and obtain a receipt describing what was received. Keep scans and a list of every original document.
Protect yourself from grievance scams
Use the official Bima Bharosa portal and contact details. The live portal states that Bima Bharosa (IGMS) does not ask complainants or policyholders for payments of any kind. Do not scan a QR code, click a payment link or transfer money to “release” an insurance settlement or accelerate a grievance. Verify unexpected messages through the insurer’s published channel or IRDAI’s official contact route.
Quick Recap
A concise action plan
- Read the policy procedure, schedule, exclusions, limits and notice requirements.
- Notify the insurer or TPA through the specified channel and save the acknowledgement.
- Collect the claim form, itemised bills, discharge summary, prescriptions, reports, payment proof and correspondence relevant to the claim.
- Submit readable copies, track every request and record the last necessary document date.
- If denied, reduced or delayed, obtain the written reason and policy clause.
- Send a documented complaint to the insurer’s GRO and retain dated proof of receipt.
- Allow the applicable insurer-grievance period and assess the written response.
- Use Bima Bharosa with the GRO record if the response is unsatisfactory or absent, and retain the token.
- Check current Ombudsman rules, jurisdiction and value limits before filing an eligible dispute.
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