Claim rejected or reduced? How to ask for a review
Make the disputed decision, the supporting evidence and the correction you want easy to identify.
“What should my complaint say, and when can I escalate it?”
Get the written reason and clause, then complain to the insurer’s grievance officer with the evidence and correction you want. The insurer has 14 days to resolve it. An unsatisfactory reply, or a month without one, can open the Insurance Ombudsman route: a free service for eligible insurance disputes, with online, email and written filing. Its one-year filing limit has different starting dates depending on the response. Check the date table below. Bima Bharosa can track a grievance; it is not a compulsory step before the Ombudsman. [1] [2] [3] [4]
About 7 min · 3 figuresSources checked 1 October 2026
Check what was refused
Cashless declined: the insurer has refused the requested direct-payment arrangement with the hospital. That alone does not decide whether reimbursement is payable. Ask why cashless was declined and what is needed for the reimbursement route. [5]
Claim rejected: obtain the decision and the particular policy condition relied upon.
Claim partly paid: obtain the itemised deductions and the calculation for each one.
The health circular requires reasons for rejection or partial disallowance to refer to specific policy terms. You should not have to infer the reason from the difference between two totals. [1]
Make the dispute specific
Consider a constructed example from our claim-deductions article. On a ₹4,55,869 bill, the settlement pays the deluxe room at the eligible single-room rate, excludes ₹9,000 of items, and reduces the surgeon, theatre and anaesthetist fees by ₹51,932 in the proportion of the eligible room rent to the room rent charged, ₹12,500 to ₹16,800. The family accepts the ₹21,500 of room excess and the ₹9,000. It asks for a review of the ₹51,932. [6]
A ₹4,55,869 bill
Separate the accepted amount from the dispute
| Part of the shortfall | Amount | Family’s position |
|---|---|---|
| Room excess | ₹21,500 | Accepted for this example |
| Excluded items | ₹9,000 | Accepted for this example |
| Room-rent ratio applied to surgeon, theatre and anaesthetist fees | ₹51,932 | Disputed |
| Total shortfall | ₹82,432 | ₹51,932 requested for review |
The family has a tariff showing the same relevant fees for the eligible single room and the deluxe room used. They check the policy’s definition of associated medical expenses, which names those fees as ones a proportionate deduction applies to, and its room clause, which speaks of expenses that vary with the room rent. They attach those pages, the tariff and the bill, then ask why the ratio was applied to charges that did not change. A different definition or tariff could change the argument. [6]
This is an illustration of how to frame a dispute, not a finding that the family would win. If the whole rejection is disputed, the same method applies: identify the reason and the evidence answering it. You do not need to accept an amount merely to make the complaint narrow.
Send one clear complaint
Use the insurer’s current grievance contact, available through its website, your Customer Information Sheet or the regulator’s directory. An agent or hospital desk can help, but keep the written complaint and acknowledgement yourself. [1] [4] [7]
If the decision came through a TPA, the third-party administrator handling the claim, or through an employer, address the formal complaint to the insurer’s grievance officer. Keep the TPA or employer reference so the insurer can trace it. [1] [4] [7]
A useful starting text is: [7]
Subject: Review requested - policy [number], claim [number]
Patient: [name]. Policyholder: [name]. Admission and discharge dates: [dates]. Contact details: [email and phone].
I am challenging the decision dated [date], received on [date], concerning [rejection or specific deduction]. The amount disputed is ₹[amount].
The reason given is [reason and clause]. I disagree because [brief explanation]. I attach [the document or calculation supporting it].
Please review [the specific issue] and provide [the payment, correction or explanation requested]. Please acknowledge this complaint with its reference number and date of receipt.
Attach the schedule, relevant wording, decision letter and the documents needed to understand the dispute. Include the settlement breakdown and itemised bill for a deduction, and relevant medical records where the stated reason concerns treatment or history. Keep a dated copy of everything sent. Save the portal acknowledgement or email receipt; for post, keep the tracking and delivery confirmation. Follow up for the complaint reference and receipt date if they are missing. [7]
The same route serves a complaint that is not about a claim, such as a renewal price or the record of a proposal; change the subject line and attachments to match. [2] [3]
The insurer’s grievance deadline is 14 days from receipt. If unresolved or the response is unsatisfactory, Bima Bharosa provides a registration and tracking route with the regulator. Its complaint record is useful, but it does not replace the separate Ombudsman filing. [2] [4]
When the Ombudsman route opens
You must first have complained to the insurer in writing. You can then approach the Insurance Ombudsman if the complaint is rejected, you are dissatisfied with the reply, or no reply is received within one month after the insurer receives the complaint. You do not have to wait out that month after receiving an unsatisfactory response. [3]
There is no filing fee. The Council’s guidance provides for online, email and written filing; the process does not provide for representation through a lawyer. Personal policies and eligible complaints by members of group policies are within its scope. [3]
The compensation sought must fall within the applicable ₹50 lakh limit. The same matter cannot already be pending before, or have been disposed of by, a court, Consumer Commission or arbitrator. Check these conditions before choosing the route. [3]
Keep these dates separate: [2] [3]
Complaint and filing rules
Keep sending, receipt and reply dates separate
| What the date governs | Trigger | Rule |
|---|---|---|
| Insurer’s grievance response | Insurer receives the complaint | Within 14 days |
| Ombudsman access after silence | Insurer receives the written complaint | No reply within one month |
| Ombudsman filing after an unsatisfactory decision | You receive that decision | Within one year |
| Ombudsman filing where no reply comes | One month expires from sending the written complaint | Within one year after that expiry |
A late complaint may be accepted in appropriate cases, but do not rely on that exception. Keep both sending and receipt records. These deadlines are not all calculated from the date on the original claim letter. [3]
An Ombudsman award binds the insurer, which must comply within 30 days of receiving it. A complainant dissatisfied with the outcome can still use the normal legal process. This is not a promise that a complaint will produce a payment. [3]
Other routes, and when to consider them
A Consumer Commission can also decide disputes, including cases unsuitable for the Ombudsman. The usual filing limit is two years from the cause of action, the event giving rise to the complaint. Identifying that date can require legal advice. Do not assume correspondence or an internal appeal automatically restarts it. The e-Jagriti platform supports consumer case filing. [8]
For a high-value dispute, a limitation concern or a signed settlement whose effect is unclear, getting legal advice before choosing where to file can be useful. [7]
Other routes and practical help
Choose help for the task at hand
| Route or help | What to use it for |
|---|---|
| National Consumer Helpline, 1915 | Help before filing a legal case; it does not issue a binding judicial decision. |
| CPGRAMS (Centralised Public Grievance Redress and Monitoring System) | Registers and forwards public grievances; it does not replace a body that decides the dispute. |
| Permanent Lok Adalat | A route for eligible public-utility disputes, including insurance, before court proceedings; check the local body’s powers and eligibility. |
| Agent, broker, employer or hospital desk | Help with records and follow-up; retain the insurer’s formal response. |
| Social media | Additional outreach if useful; do not rely on it to preserve a filing deadline or expose medical and policy details. |
A review can correct an error or resolve a disputed interpretation. It does not promise removal of a valid contractual deduction. Keep a complaint file with the decision, supporting evidence, requested correction and proof of receipt. Put the next applicable date on your calendar while waiting for the reply. [7]
Where the numbers come from
Sources checked on 1 October 2026. Product facts describe the cited document versions. Worked examples and worksheets are labelled in their captions.
- Health Insurance Master Circular. 29 May 2024, ref. IRDAI/HLT/CIR/PRO/84/5/2024, paras 4, 17 and 19: information sheet, claim reasons and grievances. Checked 25 September 2026.Read the sourceRead the circular PDF (mirror), opens in a new tababcd
- Protection of Policyholders' Interests Master Circular. 5 September 2024, ref. IRDAI/PP&GR/CIR/MISC/117/9/2024, grievance provisions, printed p.33. The 14-day requirement governs this account; the Bima Bharosa FAQ also contains older 15-day wording. The complaints mechanism applies to any policyholder not satisfied with the insurer's services, not only to claims.Read the sourceRead the circular PDF (mirror), opens in a new tababcde
- Council for Insurance Ombudsmen. Insurance Ombudsman Rules, consolidated to 9 November 2023, rules 2, 13, 14 and 17, read with the Council FAQ. Checked 25 September 2026; rule 13(1) re-read 1 October 2026. Rule 14 distinguishes receipt for the no-response eligibility test from sending for the no-response filing-period trigger. Rule 13(1) also lists premium disputes, policy servicing and a policy not matching the proposal as grounds.Read the source (PDF), opens in a new tabRead the Council FAQabcdefghi
- Bima Bharosa. FAQ: registration, forwarding and tracking. Use current insurer grievance contact details; the complaint record does not replace an Ombudsman filing.Read the sourceFind insurer grievance officersabcd
- HDFC ERGO, Optima Secure. Policy wording, UIN HDFHLIP26058V082526. Cashless denial and reimbursement, p.49 clause (g), with claims procedures on pp.50–52.Read the source (PDF), opens in a new taba
- Constructed dispute using a hospital tariff and room clause. The settlement modelled in the claim-deductions article: assumed surgeon ₹93,500, theatre ₹79,475 and anaesthetist ₹29,920 reduced by 12,500 ÷ 16,800 give per-line rounded payments ₹69,568, ₹59,133 and ₹22,262. Disputed reduction ₹51,932; plus ₹30,500 accepted deductions = ₹82,432. Star Comprehensive, UIN SHAHLIP26044V092526, pp.7–9, and Sir Ganga Ram Hospital's 2025–26 tariff, pp.1 and 3, are evidence for the illustration, not a decided case.Read the source (PDF), opens in a new tabRead the hospital tariff (PDF), opens in a new tababc
- Editorial guidance. The complaint text, document selection and practical next steps are a starting point, not a decision on the merits, forum or deadline of an individual dispute.abcdefg
- Consumer Protection Act, 2019, and NIC. Section 69 provides the ordinary two-year limitation from the cause of action. NIC describes e-Jagriti's consumer case filing functions. No commission jurisdiction or case-specific limitation date is determined here.Read the source (PDF), opens in a new tabRead about e-Jagritia
- Consumer and public-grievance assistance. National Consumer Helpline, Department of Financial Services grievance guidance and NALSA FAQ. These are supplementary routes, not compulsory consecutive stages. Permanent Lok Adalat jurisdiction and eligibility need a separate check.Read the sourceRead the public-grievance guidanceRead the NALSA FAQCPGRAMS portala