In an emergency, if your health insurance claim is rejected or you are given less amount than the fair claim, you must know what to do in such a situation.
Most people buy a health policy with the hope that they will never need to use it, and they also have the confidence that the policy will help them in case of an emergency.
However, they realize the truth when they use the policy. In many cases, it happens that the claims of policyholders are rejected even though they are paying premiums regularly. Such a rejection would be an unimaginable blow to policyholders, especially if they rely heavily on this cover for financial support.
If you too have to face such a situation, then you must know how you can get your fair claim amount.
What to do after health insurance claim is rejected?
If faced with such a situation, first study the reasons for rejection and the course of action mentioned in the policy. Senior Supreme Court Advocate Sanjay Sen said, “In case of rejection, a protocol is given in the policy to file the claim itself and take it forward. “Most insurance companies have set procedures for such situations.”
You can contact the Grievance Redressal Officers (GROs) of the concerned health insurance company. Policyholders can approach the relevant ombudsman in case of rejection, although they should first contact the insurance company.
Shaubhik Dasgupta, partner, Pioneer Legal, said, “If an insurance claim has been rejected by an insurer or if the claim amount paid is less than the expenses covered under the policy, the aggrieved policyholder should first approach the concerned insurer before approaching the Ombudsman. A complaint has to be lodged. After this, the complainant can approach the Lokpal or the consumer court, but both should not be done simultaneously.
Is it necessary to file an appeal again with the health insurance company after the claim is rejected? Manmeet Kaur, partner, Karanjawala & Company, suggests that it is not necessary to file an appeal again with the health insurance company after the claim is rejected. “However, in cases where the insurance companies have rejected the claim informing them about the reasons for such rejection/refusal, the policyholder may re-file the claim after rectifying such deficiencies,” he said.
But when policyholders are left with no other option, they can approach the appropriate forum.
Contact IRDAI
You can contact the Grievance Redressal Cell of the Consumer Affairs Department of IRDAI by calling toll free number 155255 or 1800 4254 732 or sending an e-mail to complaints@irdai.gov.in.
